South Dakota > Statewide > Department Of Revenue > Special Taxes Division > Alcohol
Alcoholic Beverage Carrier License Application - South Dakota
| Alcoholic Beverage Carrier License Application Form. This is a South Dakota form and can be used in Alcohol Special Taxes Division Department Of Revenue Statewide . |
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Date Received_________________ Date Issued___________________ License No.________________________ South Dakota Alcoholic Beverage Carrier License Application Mail to: South Dakota Department of Revenue, Special Tax Division, 445 East Capitol Ave, Pierre, SD 57501-3185 A. Owner Name and Address B. Business Name and Mailing Address Telephone #: C. Vehicle License Numbers: Carrier's license: $100.00 per calendar year (Mark one) New License [ ] Re-issuance [ ] Have you ever been convicted of a felony? Yes [ ] No [ ] Certificate: The undersigned applicant certifies under the penalties of perjury, that all statements herein are true and correct; that the said applicant complies with all of the statutory requirements for the class of license being applied for and in additional agrees to permit agents of the Department of Revenue access to the licensed premises and records as provided in SDCL 35-2-2.1 and agrees this application shall constitute a contract between applicant and the State of South Dakota entitling the same or any peace officers to inspect the premises (conveyances), books and records of the applicant for the purpose of enforcing the provisions of Title 35 SDCL, as amended. Signed this ______ day of _________________, 20_____ Signature ________________________________________ For Department of Revenue use only Amount of license fee collected: ______________ STATE LIQUOR AUTHORITY: APPROVAL ___________ REVIEW___________ Date deposited:___________________________ Deposited by:________________ Corporate/Partnership/LP/LLC applicants please complete other side American LegalNet, Inc. www.FormsWorkFlow.com Company supplement information (For corporate/partnership/LP/LLC applicants) If supplement unchanged from last year check this box and sign below. State of South Dakota :ss County of ) We, the undersigned, being first duly sworn upon oath, supply the following information: Name of corporation/partnership/LP/LLC___________________________________________________________________________ Address of office and principal place of business of corporation/partnership/LP/LLC__________________________________________ Date of incorporation _________________________________________________________________________________________ Date of last report filed with Secretary of State ______________________________________________________________________ Are all managing officers of this corporation/partnership/LP/LLC of good moral character? _____________________________________ Have any of the managing officers of this corporation/partnership/LP/LLC ever been convicted of a felony? ________________________ Name, title of office, occupation and address of each of the officers/owners of the corporation, partnership, LP or LLC: Name Office Address Occupation ) Affidavit Name, address and occupation of each of the directors of the corporation: Name Address Occupation Name and address of each of the stockholders and percentage of shares owned or held by each: Name Address Percentage of Shares Name of any officers, directors, partners or stockholders of applicant having a financial interest or capital stock in any other retail liquor outlet: Name Type of License, Financial Interest Held, and Address of Retail Outlet Where and with whom are all company records kept, such as charter, by-laws, minutes, accounts, notes payable, and notes and accounts receivable, etc? With signature the applicant agrees to the following: That the applicant company will comply with all provisions of ARSD chapter No. 64:75:02 of the Department of Revenue, relating to the transfer of stock and prior approval of the transfer of such stock by the Secretary of Revenue and violation of any of the provisions of said regulation or failure to comply therewith, whether by the undersigned corporation, partnership/LP/LLC or by any stockholder thereof, or by anyone interested in said company, shall constitute cause for revocation or suspension of any license issued pursuant to and in reliance on this application, or for refusal to renew such license upon expiration thereof. We the undersigned officers and directors of the applicant company acknowledge that the within supplement application form is true and correct in every respect and that there exists no financial arrangement concerning this or any other alcoholic beverage license than that expressly set forth above. If company stock is to be transferred we ask for approval of such voluntary stock transfer. Signature of Authorized Officer/Director/Partner ______________________________________________________________________ Subscribed and sworn to before me this __________ of ________________________, _________________ County, State of South Dakota. My commission expires __________________________ ______________________________________________ (Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com
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