Wyoming > Statewide > Wyoming Liquor Commission
Limited Transportation Liquor License Application WLD-612 - Wyoming
| Limited Transportation Liquor License Application Form. This is a Wyoming form and can be used in Wyoming Liquor Commission Statewide . |
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WLD-612 (6/04) STATE OF WYOMING Department of Revenue Liquor Division 1520 E 5th Street Cheyenne, WY 82002-0110 (307) 777-7233 Limited Transportation Liquor License Application Type of Business: Railroad Bus Limousine ____________(Other) Type of License Applied for: Applicant: Contact Person: Company Location: Mailing Address: Railroad: Annual (Fee $250.00/direction) 24 Hour (Fee $25.00/direction) ? Charter: Annual (Fee $250.00) 24 Hour (Fee $25.00) D/B/A: Phone: ( City: City: State: State: State: CORPORATION LLC LLP ) Zip: Zip: Vehicle License Plate Number: FILING AS (CHOOSE ONLY ONE) INDIVIDUAL PARTNERSHIP NOTE: Individual and Partnership filers must be domiciled residents of Wyoming for at least one year and not claimed residence in any other state in the last twelve months, and provide personal information in table below. Applicants Legal Name Date of Birth DO NOT LIST PO BOXES Residence Address, Street, City, State & Zip Residence Phone Number Have you been a DOMICILED resident for at least 1 year and not claimed residence in any other statein the last year? Have you been Convicted of a Felony Violation? Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) If a corporation, LLC or LLP 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, LLC or LLP. Use back of form if additional space is needed. Applicants Legal Name Date of Birth DO NOT LIST PO BOXES Residence Address, Street, City, State & Zip Residence Phone Number For corp or LLC. No of years in corp or LLC For corp or LLC. % of Stock Held Have you been Convicted of a Felony Violation? Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES YES NO NO YES YES NO NO YES YES NO NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) By filing this application, I agree to operate in Wyoming under the requirements of W.S.12-2-202 and all other applicable Wyoming laws and rules, and to file required sales tax reporting documents and taxes. By signing this application, I acknowledge for __________________________________________(Business Name) that all of the information provided is true and correct, and that I agree to meet the Wyoming operating conditions specified above. This application must be signed by an owner, partner, corporate office or LLC/LLP member. VERIFICATION OF APPLICATION (Requires signatures by ALL Individuals, ALL Partners, TWO (2) LLC Members, TWO (2) Corporate Officers/Directors, or TWO (2) LLP Members) W.S.12-4-102(b) Under penalty of perjury, and the possible revocation or cancellation of the license, I swear the above stated facts, are true and accurate. Dated this _______ day of _______________, _______. For Liquor Division Use Only Reviewer Initials Date Clerk Agent ________________________________________________ Applicant ________________________________________________ Applicant American LegalNet, Inc. www.FormsWorkflow.com
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