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Application For Solicitor Registration DLC 1504 - Ohio
| Application For Solicitor Registration Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
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APPLICATION FOR SOLICITOR REGISTRATION $50.00 FEE - MADE PAYABLE TO THE OHIO DIVISION OF LIQUOR CONTROL (See Instructions on Page 2) STATE OF OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD - P.O. BOX 4005 REYNOLDSBURG, OH 43068-9005 614-644-2411 SECTION I NAME: SALES PERSON OR AGENT REGISTRATION INFORMATION BIRTH DATE: CITY: STATE: BUSINESS PHONE NUMBER: ZIP CODE: RESIDENCE ADDRESS: RESIDENCE PHONE NUMBER : EMAIL ADDRESS: Please indicate your current status under which you are a salesperson or agent. I am a salesperson or agent employed by an Ohio manufacturer, Ohio wholesale distributor, or a supplier of beer, wine, mixed beverages or spirituous liquor. I am a salesperson, agent, or trade marketing professional who is employed by a trade marketing company or broker that represents the products of an Ohio manufacturer, Ohio wholesale distributor, or supplier of beer, wine, mixed beverages or spirituous liquor. I am a salesperson or agent who is self employed and represents the products of an Ohio manufacturer, Ohio wholesale distributor, supplier or broker of beer, wine, mixed beverages or spirituous liquor. SECTION II SALES PERSON/ AGENT PERSONAL INFORMATION YES NO 1. Is applicant employed by an Ohio retail liquor permit holder? If YES, please list the name of the retail permit holder and in what capacity you are employed on the line provided: 2. Has applicant ever been denied, had revoked, or had a renewal rejected for any type of liquor permit in this, or any other state? If YES, please explain? 3. Has applicant ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? If YES, a full explanation and copy of certified journal entry, sentence or disposition MUST be attached. SECTION III YES NO YES NO PLEASE COMPLETE THIS SECTION INDICATING THE OHIO MANUFACTURER, OHIO WHOLESALE DISTRIBUTOR, SUPPLIER, BROKER OR TRADE MARKETING COMPANY FOR WHOM YOU ARE A SALESPERSON OR AGENT. PHONE NUMBER: CITY: STATE: ZIP CODE: NAME OF COMPANY: ADDRESS OF COMPANY: EMAIL ADDRESS: Please check the appropriate box regarding the company for whom you are a salesperson or agent: 1. The above referenced company holds an Ohio permit, Ohio supplier registration or Ohio Spirits Vendor registration with the Division of Liquor Control. Please indicate permit or registration number The above referenced company does not hold an Ohio permit, Ohio supplier registration or Ohio Spirits Vendor registration with the Division of Liquor Control and operates as a broker or trade marketing company for an Ohio manufacturer, Ohio wholesale distributor or supplier. 2. *Attach to this application a letter of confirmation from your employer or the company you represent, stating that you are currently employed by or a salesperson or agent of such company and that you are authorized to sell and represent their products. SECTION IV NOTARIZED SIGNATURE OF APPLICANT being first duly sworn, according to law, depose and say that the statements I, (Please Print Name) and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Applicant) _____________________ (Title) _______________ (Date) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) FOR DIVISION USE ONLY ID# DATE ISSUED CHECK# AMOUNT$ _______________ (Notary Expiration) Superintendent Approval/Denial: DLC 1504 Approved Denied (Signature) American LegalNet, Inc. www.FormsWorkFlow.com EOE/ADA SERVICE PROVIDER (Date) REVISED 03/22/2012 FOR TTY USERS DIAL 1-800 -750-0750 INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR SOLICITOR REGISTRATION A "Trade marketing professional" is defined as an individual who is an employee of, or is under contract with, a trade marketing company and who has successfully completed a training program on subjects such as the illegal serving of alcohol to persons under 21 years of age. A "Trade marketing company" is defined as a company that solicits the purchase of beer and intoxicating liquor and educates the public about beer and intoxicating liquor. A "Broker" is defined as a company that solicits sales of alcoholic beverages on behalf of a manufacturer or supplier, but generally does not take possession of the beverages. A "Solicitor" is defined as an individual who solicits sales of alcoholic beverages on behalf of a manufacturer, supplier, wholesale distributor, or broker, and generally does not take possession of the beverages. Any individual acting as an agent, solicitor, trade marketing professional or salesperson for any manufacturer, supplier, wholesale distributor, trade marketing company or broker of beer, wine, mixed beverages, or spirituous liquor which products are to be sold or produced in the state of Ohio, who is licensed or otherwise authorized to do business in Ohio shall be required to register with the division every two years upon the individual's date of registration pursuant to section 4303.25 of the Revised Code. This registration is also required for all individuals soliciting the Ohio Division of Liquor Control and Ohio permit holders. 1. Please include a $50.00 registration fee made payable to the Ohio Division of Liquor Control. 2. Be sure to have the application notarized. 3. Please direct any questions to (614) 644-2411. Section I Complete all personal information for the individual applying for the solicitor registration and indicate if the applicant is employed by an Ohio permit holder (i.e., manufacturer, supplier or wholesale distributor), self employed or an employee of a trade marketing company, or a broker that represents alcoholic beverages. Section II Answer all personal information questions and supply additional information if so required. Section III Complete this section listing the company you are employed by or if self employed, the company you act as an agent for. Check box #1 if the company holds an Ohio permit, Ohio supplier registration or Ohio spirits vendor registration ("VR") with the Division of Liquor Control. Indicate their permit, registration number or VR number. Check box #2 if the company does not have an Ohio permit, registration or VR number and the company solicits sales of alcoholic beverages on behalf of a manufacturer, supplier or wholesale distributor. In this case, the company would be considered a broker or
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