Wyoming > Statewide > Wyoming Liquor Commission
Application For Class A Industry Representative License WLD-05 - Wyoming
| Application For Class A Industry Representative License Form. This is a Wyoming form and can be used in Wyoming Liquor Commission Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
WLD-05 (7/07) NEW RENEWAL DEPARTMENT OF REVENUE LIQUOR DIVISION 6601 Campstool Road Cheyenne, WY 82002 Rec'd application: Rec'd cash/check: Reviewed by: APPLICATION for Class "A" INDUSTRY REPRESENTATIVE LICENSE LICENSE TERM: July 1, 20__ through June 30, 20__ Applicant: Residence Address: Mailing Address: Business Name: Home Phone: RENEWAL Business Phone: Fax Number: No No E-Mail Address: 1. Are you 18 years of age or older? Yes 2. Are you domiciled in Wyoming? Yes 3. Do you presently hold any interest (directly or indirectly) in any type of retail liquor license or retail malt beverage permit within the State of Wyoming? Yes No (b) If "Yes," please attach a full explanation. 4. Are you currently employed by a licensee as defined in W.S.12-1-101(a)(viii)? Yes No 5. Have you been convicted of a felony or a violation of federal or state statutes relating to sale or manufacture of alcoholic beverages in the ten (10) years preceding this application? Yes No 6. Have you ever had a liquor or industry representative license denied, canceled, suspended or revoked? Yes If "Yes," please attach a full explanation? No 7. (a) List below all liquor, wine, or malt beverage manufacturers, wholesalers, rectifiers, importers, etc., which you will represent within the State of Wyoming. Describe your employment/contractual arrangements with each company, i.e., salaried, broker, commission, etc. Attach additional sheet if necessary. COMPANY ADDRESS EMPLOYMENT/CONTRACTUAL ARRANGEMENT (b) If application is for a NEW license, or you are adding companies, please attach written verification from each vendor of your employment or contractual relationship with them. The verification should include the vendor's request for you to be licensed to represent it's particular brand or brands in Wyoming. 8. I have read and understand the laws and rules of the State of Wyoming regarding the advertisement and promotion of alcoholic beverages and will abide by these laws and rules. I understand that violation of these laws and rules may constitute cause for denial, suspension or revocation of my license. _________________________________________________ Signature _____________________ Date ________________________ $100.00 FEE AND UPDATED VENDOR LIST IS DUE WITH APPLICATION LICENSE RENEWABLE ANNUALLY 45 DAYS PRIOR TO EXPIRATION DATE OF JUNE 30TH Payment Processed: _____/_____/_____ Control Number: __________________ American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
