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Application For Manufacturer Rectifier Or Importer License WLD-029 - Wyoming
| Application For Manufacturer Rectifier Or Importer License Form. This is a Wyoming form and can be used in Wyoming Liquor Commission Statewide . |
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WLD-29 STATE OF WYOMING LIQUOR DIVISION APPLICATION FOR: NEW RENEWAL TRANSFER OF OWNERSHIP TRANSFER OF LOCATION TYPE OF LICENSE MANUFACTURER/RECTIFIER IMPORTER APPLICATION FOR MANUFACTURER/RECTIFIER OR IMPORTER LICENSE LIQUOR DIVISION USE ONLY Date Received: Reviewed By: Date Approved: Date License Issued: For the period 20 to 20 PART I (TO BE COMPLETED BY ALL APPLICANTS) 1) Applicant name and principal address. (If an individual owner, give full names; if a partnership, give full name of each partner; if a corporation, give the name of the corporation.) 2) Trade name to be used in operation of business.: 3) Address of premises covered by this application. (Number and street, city, county, state, zip code and phone number.) 4) List states in which you are or have previously been licensed as a manufacturer/rectifier or importer. STATE DATES 5) Is the business a new enterprise?: (If acquired from holder of Wyoming Malt Beverage License and a basic permit under Federal Alcohol Administration Act, complete items a through c.) YES NO A. Name and address of license holder from whom business acquired. (If change in stock control, state name as shown in item 1 above.) B. Date of change in ownership or stock control.. C. Date business to be acquired by applicant.. 6) Applicants place of business OWNED LEASED RENTED A. Duration of lease or rental. B. If leased or rented, name and address of owner(s).) American LegalNet, Inc. www.FormsWorkflow.com 7) Do you now have or have you submitted application for: A. Federal Basic Permits (Give dates and numbers, if known)? YES YES NO NO B. Bureau of Alcohol, Tobacco and Firearms Special Occupational Tax? 8) Does the applicant or any member of your partnership or any officer, director or stockholder of the corporation: A. Hold any interest, directly or indirectly, in any retail license or permit issued in the State of Wyoming? (If yes, give detail) YES B. Had a criminal record equal to a felony conviction under Wyoming or Federal Law, or a conviction for a violation of Wyoming or Federal Law relating to the sale or manufacture of alcoholic or malt beverages? (If yes give details) YES NO NO C. Have you been a resident of the State of Wyoming for at least one (1) year immediately preceding the date of this application? (If no, how long have you claimed residency?) YES NO 9) List below all products which you propose to manufacture, rectify or import within the State of Wyoming. PRODUCT BRAND NAME DESCRIPTION NOTE: The Wyoming Liquor Division must be notified in writing immediately of any changes in product, discontinuance or addition of, change of label etc... American LegalNet, Inc. www.FormsWorkflow.com PART II (TO BE COMPLETED IF APPLICANT IS AN INDIVIDUAL PROPRIETOR OR A PARTNERSHIP) 10) Information relating to each partnership or individual applicant. NAME ADDRESS DATE OF BIRTH PERCENT INTEREST % % % % PART III (TO BE COMPLETED IF APPLICANT IS A CORPORATION) 11) In relation to the corporation, give the following: A. Date of Corporation: B. Is the corporation qualified with the Secretary of State to transact business within the State of Wyoming? YES NO OFFICERS/DIRECTORS NAMES ADDRESS DATE OF BIRTH TITLE 12) Does applicant either directly or indirectly have actual or legal control over any other corporation or is the business actually or legally controlled by any other corporation, whether such control is effected through stock ownership or in any YES NO other manner? (if yes, state the extent and manner of such control, the nature of the business, and the name and address of each corporation(s) together with the names and addresses of the officers and directors of each such corporation.) American LegalNet, Inc. www.FormsWorkflow.com 13) A. BY SUBMISSION OF THIS APPLCATION, THE APPLICANT HEREBY AGREES THAT HE WILL OPERATE IN CONFORMITY WITH THE LAWS OF THE STATE OF WYOMING, THE FEDERAL ALCOHOL ADMINISTRATI0N ACT, AND LAWS RELATING TO ENFORCEMENT THEREOF; INCLUDING TAXES WITH RESPECT THERETO AND ALL APPLICABLE RULES AND REGULATIONS MADE PURSUANT TO LAW WHICH ARE NOW OR MAY HEREAFTER BE IN FORCE. B. BY VIRTUE OF THE TERMS AND CONDITIONS OF THE WHOLESALE MALT BEVERAGE LICENSE WHICH MAY BE ISSUED HEREUNDER, THE APPLICANT HEREBY STATES AND AFFIRMS TO PROVIDE THE NECESSARY SERVICE, DELIVERY AND MAINTENANCE OF ALL MALT BEVERAGE BRANDS DECLARED IN NUMBER 9(A) ABOVE TO ALL RETAIL LICENSEES AND PERMITEES THROUGHOUT THE ENTIRE DESIGNATED GEOGRAPHICAL TERRITORY(S). C. UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS APPLICATION INCLUDING ACCOMPANYING STATEMENT AND TO THE BEST OF MY KNOWLDGE AND BELIEF, IT IS TRUE, CORRECT AND COMPLETE. PART V VERIFICATION AND ACKNOWLEDGEMENT (TO BE COMPLETED BY ALL APPLICANTS) STATE OF WYOMING ) COUNTY OF Before Me, ) SS. , (specify) a Notary Public/Officer (Printed name of Notary or other officer authorized to administer oaths) authorized to administer oaths in and for personally appeared (Insert Names) County, State of Wyoming, name he/she being first duly sworn by me upon his oath, says that the facts alleged in the foregoing instrument are true. (Seal) 1. 2. 3. My commission expires: Witness my hand and official seal: (Notary public or other officer authorized to administer oaths) 4. Title When a document you are notarizing or verifying has either an oath or verification, then please actually administer an oath. Dated: Note: Please void any blanks not signed before you at time of authentication. American LegalNet, Inc. www.FormsWorkflow.com
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