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Application For Wholesale Malt Beverage License WLD-033 - Wyoming
| Application For Wholesale Malt Beverage License Form. This is a Wyoming form and can be used in Wyoming Liquor Commission Statewide . |
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WLD-033 (7/2012) STATE OF WYOMING LIQUOR DIVISION 6601 Campstool Road Cheyenne, WY 82002-0110 APPLICATION FOR: NEW $250.00 RENEWAL $250.00 APPLICATION FOR WHOLESALE MALT BEVERAGE LICENSE W.S. 12-2-201 For period to LIQUOR DIVISION USE ONLY Date Received: Reviewed By: Date Approved: Date License Issued: PART I (TO BE COMPLETED BY ALL APPLICANTS) 1) Applicant name and principal address: (If an individual owner, give full name; if a partnership, give full name of each partner; if a corporation, give the name of the corporation or LLC.) 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) Address of any satellite warehouses: (State whether malt beverages will be sold from satellite warehouses.) 5) Is the business a new enterprise: (If acquired from holder of Wyoming Wholesale 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) Does the applicant or any member of your partnership or any officer, director or stockholder of the corporation or LLC: A. Hold any interest, directly or indirectly, in any liquor license or permit issued in the State of Wyoming? YES (If yes, give details) NO B. Have 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? YES (If yes, give details) NO C. Been a resident of the State of Wyoming for at least one (1) year immediately preceding the date of this application? YES NO 7) List names of brewers or legally authorized agents, distributors or importers of malt beverages who have designated a geographic territory within which you may sell their malt beverage products to qualified liquor licensees or permitees. (If additional space is required, complete on a separate piece of paper and attach). BREWER/IMPORTER BRANDS TERRITORIAL COVERAGE DATE OF CERTIFICATION State law requires all malt beverage described above be available for purchase and delivery to all liquor licensees or malt beverage permittees within the territory designated. American LegalNet, Inc. www.FormsWorkFlow.com PART II (TO BE COMPLETED IF APPLICANT IS AN INDIVIDUAL PROPRIETOR OR A PARTNERSHIP) 8) Information relating to each partnership or individual applicant. NAME RESIDENCE ADDRESS DATE OF BIRTH PART III (TO BE COMPLETED IF APPLICANT IS A CORPORATION OR LLC) 9) A. B. Date of incorporation: Is the corporation or LLC qualified with the Secretary of State to transact business within the State of Wyoming? YES NO 10) List the full names and residence address of all the officers and directors and of all shareholders owning jointly or severally ten percent (10%) or more of the stock of the corporation or LLC NAME RESIDENCE ADDRESS DATE OF BIRTH % OF STOCK 11) Does applicant, either directly or indirectly, have actual or legal control over any other corporation or LLC , or is the business actually or legally controlled by any other corporation or LLC, whether such control is effected through stock ownership or in any other manner? YES NO (If yes, state the extent and manner of such control, the nature of the business, and the name and address of such corporation(s) or LLC(s) together with the names and addresses of the officers and directors of each such corporation or LLC.) VERIFICATION AND ACKNOWLEDGEMENT (TO BE COMPLETED BY ALL APPLICANTS) By submission of this application, the applicant hereby agrees that: a) b) c) d) e) All applicable state and federal laws will be adhered to; All applicable state excise taxes will be timely reported and paid; All liquor licensees and malt beverage permitees within the territory designated may purchase and have delivery services of all malt beverage brands declared in this application. Signature indicates that applicant has examined this application, including accompanying statement, and to the best of applicant's knowledge and belief, it is true, correct and complete. Requires all signatures for individual and partnership, requires at least 2 signatures for corporations or LLC ) ) , (specify) a Notary Public/Officer authorized to administer oaths in and (Printed name of Notary or other officer authorized to administer oaths) STATE OF WYOMING COUNTY OF Before Me, for SS. County, State of Wyoming, personally appeared _______________________________________________ (Insert Names) and he/she being first duly sworn by me upon his oath, says that the facts alleged in the foregoing instrument are true. (Seal) My commission expires: Witness my hand and official seal: Dated: (Notary public or other officer authorized to administer oaths) 1. 2. 3. 4. (Title) American LegalNet, Inc. www.FormsWorkFlow.com
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