WLD-29 (9/14) 

                                                        Manufacturer/Rectifier                                 Rec'd app:________________ 
                                                                                                               Rec'd cash/check:_______ 
                                                      or Importer License                                      Reviewed by:___________ 
                                                                                                               Payment  
                                                             Application                                       Processed:_____________ 
                                                                         
                                                           License fee: $250.00                                Control #:______________ 
   6601 Campstool Rd, Cheyenne, Wyoming 82002 
                                                                       
                                                                 LICENSING TERM: 
                                                                      
                                               From:________           to _________ 
                                                                    
                          License #: _______________ 
                                                                     
Type of License           Importer                        Manufacturer                 Rectifier                        
                                                           
Applicant: ______________________________  D/B/A ______________________________________: 
 
Premise Address: ________________________  City: _____________  State:______   Zip: _________ 
 
Mailing Address: ________________________                 City: _____________  State: _____                           Zip: _________ 
 
Business Phone: ________________________                  Business Fax:________________________________ 
                                                                                                                                            
Contact Person:________________________________________ 
                                                                                           
List states in which you are or have previously been licensed as a manufacturer/rectifier or importer. 
   
                                    STATE                                                               DATES 
                                                                    
Is this business a new enterprise?                                                 YES                         NO        
                                                                   
Have you submitted a copy of the Federal Basic Permit?                             YES                         NO        
 
Have you registered with the Dept of Treasury,                                     YES                         NO        
Alcohol and Tobacco Tax and Trade Bureau? (TTB.GOV) 
  
                                               FILING AS (CHOOSE ONLY ONE) 
 
     INDIVIDUAL (SOLE PROPRIATOR)                           CORPORATION            LLC                           LLP 
 
Is the licensed premises:                                   Owned                  Leased                        Rented 
                                                                                                                                            
If the premises is leased, please provide a copy of the lease. 
  

 WLD-29 (9/14) 
 If applicant is an Individual(s) or Partnership:          State the name, date of birth and residence of the applicant and of 
 each applicant or partner, if the application is made by more than one individual or partnership.   
  
                                                                                              Do you hold      Have you been 
                                                                           Have you been a    any interest,    Convicted of a 
                                                                           DOMICILED          directly or      Violation 
                                                                           resident for at    indirectly, in   Relating to the 
                                                                           least 1 year and   any liquor       sale or 
                                                                           not claimed         license or      manufacture of 
                                 DO NOT LIST PO BOXES                      residence in any   permit issued in Alcoholic Liquor 
                        Date of   Residence Address, Street,   Residence   other State in the the State of     or Malt 
 True and Correct Name   Birth           City, State & Zip   Phone Number     last year?      Wyoming?         Beverages? 
                                                                           YES                YES              YES             
                                                                           NO                 NO               NO              
                                                                           YES                YES              YES             
                                                                           NO                 NO               NO              
                                                                           YES                YES              YES             
                                                                           NO                 NO               NO              
                                                                           YES                YES              YES             
                                                                           NO                 NO               NO              
                                                                           YES                YES              YES             
                                                                           NO                 NO               NO              
                                                                           YES                YES              YES             
                                                                           NO                 NO               NO              
  (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) 
                                                                
 If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited 
 Partnership:  State the name, date of birth and residence of each stockholder holding, either jointly or severally, ten 
 percent (10%) or more of the outstanding and issued capital stock of the corporation, limited liability company, 
 limited liability partnership, or limited partnership, and every officer, and every director. 
  
                                                                                              Do you hold      Have you been 
                                                                                              any interest,    Convicted of a 
                           DO NOT                                                             directly or      Violation 
                           LIST PO                                                            indirectly, in   Relating to the 
                           BOXES                                                              any liquor       sale or 
                           Residence                           No of                           license or      manufacture of 
                           Address,                           years in                        permit issued in Alcoholic Liquor 
  True and      Date of    Street, City,  Residence Phone     corp or                         the State of     or Malt 
 Correct Name   Birth      State & Zip     Number               LLC       % of Stock Held     Wyoming?         Beverages? 
                                                                                              YES              YES             
                                                                                              NO               NO              
                                                                                              YES              YES             
                                                                                              NO               NO              
                                                                                              YES              YES             
                                                                                              NO               NO              
                                                                                              YES              YES             
                                                                                              NO               NO              
                                                                                              YES              YES             
                                                                                              NO               NO              
                                                                                              YES              YES             
                                                                                              NO               NO              
                                                                                              YES              YES             
                                                                                              NO               NO              
                                                                                              YES              YES             
                                                                                              NO               NO              
  (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) 
  

 WLD-29 (9/14) 
 List all products which you propose to import, manufacture or rectify within the State of Wyoming. 
  
                   Product                       Brand Name                                                 Description 
                                                                                                  
      (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) 
                                                                                   
 Please note, any changes in product (addition or discontinuance), change or label, etc require written notification to the 
 Wyoming Liquor Division. 
                                                                                  
                                       VERIFICATION AND ACKNOWLEDGEMENT 
 By submission of this application, the applicant hereby agrees that:  
  
        a)  All applicable state and federal laws will be adhered to; 
        b)  All applicable state excise taxes will be timely reported and paid; 
        c)  Signature indicates that applicant has examined this application, including accompanying statement, and to the 
               best of applicant’s knowledge and belief, it is true, correct and complete. 
        d)  Requires all signatures for individual and partnership, 1 signature for an LLC and 2 signatures for corporations. 
 STATE OF WYOMING  ) 
                 SS. 
 COUNTY OF      ) 
  
 Before Me,                                     ,(specify) a Notary Public/Officer authorized to administer oaths in  
        (Printed name of Notary or other officer authorized to administer oaths)       
 and for        County, State of Wyoming, Personally appeared____________________________________ 
                                                                                                   (Insert Names) 
 and he/she being first duly sworn by me upon his oath, says that the facts alleged in the foregoing instrument are true. 
  
(Seal)                                                                            1.                                     
                                                                                  2.                                     
                                                                                  3.                                     
My commission expires:                                                            4.                                     
        
 Witness my hand and official seal: 
                                                                                      Dated:                                    
 (Notary public or other officer authorized to administer oaths) 
           
                                     (Title)                                          Please mail $250.00 check, application and  
                                                                                      a copy of your Federal Basic Permit to:     
  
                                                                                                Wyoming Liquor Division 
                                                                                                Compliance 
                                                                                                6601 Campstool Rd. 
                                                                                                Cheyenne, WY  82002-0110