Wine Shipper Brand Listing

North Carolina Alcoholic Beverage Control Commission Wine Shipper Brand Listing This form must be completed and submitted with the initial Wine Shipper Permit Application. There after, submit with the addition or deletion of brands. Please print or type. Page Presently being shipped into NC indicate Yes or No of Brand Name Add Remove NC Wholesaler Notified - Indicate Yes No Permittee Name: Permittee Address: Permittee Phone Number: Name of Common Carrier: Permit Number: Email Address: Approved by The Commission: Yes No OATH OF APPLICANT I certify as required by NCGS 18B-902(a) and (c)that this document is true, correct and complete to the best of my knowledge. Printed Name and Position of Authorized Official: Signature of Authorized Official: Date NC Wine Shipper Brand Listing - 8/2003 American LegalNet, Inc. www.FormsWorkflow.com