Brand Label Registration Application

Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division 444 Cedar Street, Suite 222, St. Paul, MN 55101 651-201-7500 Fax 651-297-5259 TTY 651-282-6555 https://dps.mn.gov BRAND LABEL REGISTRATION APPLICATION *Required Fields *Name of Registrant *Address *E-mail Address *City Office Use Only Approved Denied Date Amount Received License Identification Number *State *Business Phone *Zip Code If you are not the owner of this brand, you must have permission from the brand owner to register and import this label into Yes No Permission Minnesota. *As per Minnesota Rule 7515.0810. Please enter the name or company that owns this brand label. Brand Name Class Type *Alcoholic Content % by Volume Affix Complete Set of Labels (Click in the box below to upload image of label) Upload front of brand label by clicking on this box. Upload back of brand label by clicking on this box. I certify that all statements made by me on this application are true, complete and correct to the best of my knowledge. *Signature *Title and Full Name of Applicant or Authorized Representative (Please Print) *Date If Label Changed Please Provide Original Number Make Check Payable to: DPS Alcohol and Gambling Enforcement Notice A $30.00 service fee will be added to all dishonored checks. You may also be subjected to a civil penalty of $100.00 of the value of the check, whichever is greater, plus interest and attorneys fees. Number of New Brand Labels ($40 each) * = American LegalNet, Inc. www.FormsWorkFlow.com NO FEE for additions or revisions of labels * TTB COLA DOCUMENT REQUIRED WITH EACH BRAND LABEL APPLICATION