Application Ethyl Alcohol Distilled Spirits

Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street, Suite 222, St. Paul, MN 55101 (651) 201-7512 TDD (651) 282-6555 FAX (651) 297-5259 Print Form APPLICATION FOR PERMIT TO PURCHASE AND/ OR POSSESS ETHYL ALCOHOL AND/OR DISTILLED SPIRITS MAKE CHECKS PAYABLE TO: ALCOHOL AND GAMBLING ENFORCEMENT DIVISION FEE$ 20.00 Permit # _____________ PERMIT TO PURCHASE AND POSSESS ETHYL ALCOHOL BY PHYSICIANS, DENTISTS AND VETERINARIANS To be used for medicinal, chemical, pharmaceutical, or scientific purposes PERMIT TO PURCHASE AND POSSESS ETHYL ALCOHOL BY PHARMACIST To be used for the compounding of prescriptions PERMIT TO PURCHASE AND POSSESS SPIRITS AND WINE BY HOSPITAL OR SANATORIUM To be used for administering to patients upon prescription PERMIT TO PURCHASE AND POSSESS Distilled Spirits and Wine To be used exclusively in the manufacture of food products and medicines PERMIT TO PURCHASE AND POSSES ETHYL ALCOHOL To be used for the manufacture of gasohol, medicinal, pharmaceutical, antiseptic, flavoring extracts, syrups, food, scientific, chemical, mechanical or industrial products, or by any municipal county, state or federal agency, any scientific university or college or learning, laboratory used for scientific research or any hospital or sanatorium. Name of Firm , Address of the city of , Zip Code , Business Phone hereby apply for the above indicated permit (alcohol, spirits & wines) to be used exclusively as provided for by Minn Stat. Chapter 340, and liquor regulations, for a period of one year. PLEASE RETURN THIS APPLICATION WITH $20.00 FEE (Applicant Signature) Check Cash (Name of Firm) (Date) American LegalNet, Inc. www.FormsWorkFlow.com