Texas > Statewide > Alcoholic Beverage Commission
Application For Forwarding Center Authority L-105 - Texas
| Application For Forwarding Center Authority Form. This is a Texas form and can be used in Alcoholic Beverage Commission Statewide . |
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APPLICATION F O R FORWARDING CETNER AUTHORTIY (ONLY THE HOLDERS OF THE FOLLOWING PERMIT/LICENSE CLASSES MAY OBTAIN THIS AUTHORITY: MANUFACTURER'S LICENSE, NONRESIDENT MANUFACTURER'S LICENSE, BREWER'S PERMIT, DISTILLER'S AND RECTIFIER'S PERMIT, WINERY PERMIT AND NONRESIDENT BREWER'S PERMIT.) TYPE OR PRINT IN INK FORM L-105 (9/2011) TABC USE ONLY ISSUE DATE FEE SURCHARGE LATE FEE (RENEWAL ONLY) FC 1A. APPLICATION FILED FOR: Original Renewal Change Change: / / $2,000 $278 Registry No. B. If renewal or change, enter Authority Number: FC 2. APPLICATION IS FILED BY: (Indicate current manufacturing license or permit number issued by Texas and the name of entity currently holding license or permit.) TABC License/Permit Number: ALL APPLICANTS Entity Name: 3. Name of Regional Forwarding Center 4. Address or Location City County State Zip Code (9 digits) Zip Code (9 digits) - 5. Mailing Address City State 6. Area Code + Business Telephone Number ( ) / Area Code + Alternate Telephone Number ( / ) - E-mail Address (optional) TABC USE ONLY PROCESSOR REVIEW DATE WRITTEN PROCESS DATE / / END PROCESS DATE / / PROCESSOR I.D. American LegalNet, Inc. www.FormsWorkFlow.com PARTNERSHIPS/CORPORATIONS TRADE NAME: 1A. Indicate type of ownership and complete the information below: Corporation Limited Liability Company Partnership B. Federal Employer's I.D. No.: C. Entity Name: D. Charter No.: Date Approved: / / State: E. Number and class of shares, memberships or units issued: Limited Partnership FORM L-106-PC (8/2005) Limited Liability Partnership FOR ALL OFFICER(S), PARTNER(S), DIRECTOR(S), MANAGER(S), STOCKHOLDER(S) AND MEMBER(S). 2. COMPLETE THE FOLLOWING PER INSTRUCTIONS: Social Security Number Issuing State and Driver's License Number Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Title Class & No. Shares Held or % Memberships or % Interest Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Residential Address City State Zip Code (9 digits) - Social Security Number - Issuing State and Driver's License Number Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Title Class & No. Shares Held or % Memberships or % Interest Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Residential Address City State Zip Code (9 digits) - Social Security Number - Issuing State and Driver's License Number Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Title Class & No. Shares Held or % Memberships or % Interest Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Residential Address City State Zip Code (9 digits) - Social Security Number - Issuing State and Driver's License Number Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Title Class & No. Shares Held or % Memberships or % Interest Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Residential Address City State Zip Code (9 digits) - Social Security Number - Issuing State and Driver's License Number Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Title Class & No. Shares Held or % Memberships or % Interest Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Residential Address City State Zip Code (9 digits) - Social Security Number - Issuing State and Driver's License Number Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Title Class & No. Shares Held or % Memberships or % Interest Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Residential Address City State Zip Code (9 digits) - (IF YOU NEED ADDITIONAL SPACE FOR MORE NAMES, USE ADDITIONAL COPIES OF THIS PAGE) American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION F O R FORWARDING CETNER AUTHORTIY CONTINUED TRADE NAME: FORM L-105 (9/2011) PLEASE READ THIS IMPORTANT STATEMENT BEFORE SIGNING THIS APPLICATION. The holder of this authority may have an interest directly or indirectly, in on only the manufacturing level of the Alcoholic Beverage Industry. You or your agent, servant, or employee, including 3rd party operators, may not be employed in any capacity at wholesale or retail levels, may not rent or lease property or equipment from or to an entity operating at wholesale or retail levels, may not secure credit or a loan in any form for an entity at wholesale or retail levels, cannot control in any fashion the interests of a permittee or licensee at wholesale or retail levels. WARNING: Section 101.69 of the Texas Alcoholic Beverage Code is as follows: "...a person who makes a false statement or false representation in an application for a permit or license or in a statement, report, or other instrument to be filed with the Commission and required to be sworn commits an offense punishable by imprisonment in the penitentiary for not less than 2 nor more than 10 years." ACKNOWLEDGMENT If Applicant is: Who Must Sign: Individual Owner Partner Officer General Partner General Partner Office or Manager SIGN HERE: SIGNATURE OF MANUFACTURER ACKNOWLEDGMENT Individual Partnership Corporation Limited Partnership Limited Liability Partnership Limited Liability Company PRINT NAME: NAME OF MANUFACTURER Before me, the undersigned authority, on this , 20 day of the person whose name is signed to the foregoing application personally appeared and, duly sworn by me, states under oath that he or she read the said application and that all the facts therein set forth are true and correct. SIGN HERE: SEAL NOTARY PUBLIC CERTIFICATE OF CITY SECRETARY (if not in incorporated city, so state) CERTIFICATE OF CITY SECRETARY I hereby certify on this day of , 20 Beer / Wine , the location / Distilled Spirits (Circle all that apply) indicated in question 4 as the place of business is in a "wet area," for and that such location is inside the boundaries of this city.. SIGN HERE: City Secretary/Clerk , Texas SEAL CERTIFICATE OF COUNTY CLERK CERTIFICATE OF COUNTY CLERK I hereby certify on this day of , 20 Beer / Wine , the location / Distilled Spirits (Circle all that apply) indicated in question 4 as the place of business is in a "wet area," for. SIGN HERE: County Clerk County SEAL American LegalNet, Inc. www.FormsWorkFlow.com
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