Wyoming > Statewide > Wyoming Liquor Commission
Application For Class B Industry Representative License WLD-05 - Wyoming
| Application For Class B Industry Representative License Form. This is a Wyoming form and can be used in Wyoming Liquor Commission Statewide . |
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WLD-05 (7/12) 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 "B" INDUSTRY REPRESENTATIVE LICENSE LICENSE TERM: Applicant Residence Address Mailing Address Business Name Home Phone: E-Mail Address: 1. Are you 18 years of age or older? Yes 2. Are you domiciled in Wyoming? Yes No No Business Phone: Fax Number: City City State State Zip Zip through RENEWAL 3. (a) 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. (a) 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 5. Have you ever had a liquor or industry representative license denied, canceled, suspended or revoked? Yes If "Yes," please attach a full explanation. 6. (a) List below the company represented by your Class "A" Industry Representative sponsor. COMPANY ADDRESS EMPLOYMENT/CONTRACTUAL ARRANGEMENT No (b) Please attach written verification from the Class "A" Industry Representative of the company indicated above. 7. 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 ________________________ $50.00 FEE IS DUE WITH APPLICATION LICENSE RENEWABLE ANNUALLY 45 DAYS PRIOR TO EXPIRATION DATE OF JUNE 30TH American LegalNet, Inc. www.FormsWorkFlow.com
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