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WLD-33 (4/18) 
                                                                                Date Rec’d             /           / 
                                              Wholesale  
                                                                                Amount Rec’d    $ 
                                              Malt Beverage                     Cash         Recpt #: 
                                              License                           Check        Ck #: 
                                                                                Processed by:
                                              Application                                               
                                                                                Payment  Processed:        /        / 
6601 Campstool Road 
Cheyenne, Wyoming 82002-0110                    License fee: $250.00            Control Number:          
                                                          
                                                          LICENSING TERM: 
                                                            
                                   From:________ to 9/20/2019 
                                                          
                                   License #: _______________ 
                                                           
Applicant: ____________________________               D/B/A:______________________________________ 
 
Premise Address: ______________________  City: _____________  State:______   Zip: _________ 
 
Mailing Address: _______________________  City: _____________  State: _____                     Zip: _________ 
 
Business Phone: _______________________  Business Fax:________________________________ 
                                                                                                                                                              
Contact Person:________________________________________ 
                                                                                    
Address of any satellite warehouses:   
                                                                                    
                                    FILING AS (CHOOSE ONLY ONE) 
 
  INDIVIDUAL (SOLE                              CORPORATION                 LLC                LLP 
PROPRIATOR) 
 
1.  Is the licensed premises:                   Owned                       Leased             Rented 
                                                                                     
           (A)  If the premises is leased, please provide a copy of the lease. 
 
2.         Is this business a new enterprise?                                   YES        NO          
        (If acquired from holder of Wyoming Wholesale Malt Beverage License and a basic permit under Federal Alcohol Administration Act, complete items A   
         through C.) 
       (A)  Name and address of license holder from whom business acquired: 
                                                           
      (B)  Date of change in ownership or stock control:  
                                                           
      (C)  Date business to be acquired by applicant:  
                                                           
3.  Does applicant, either directly or indirectly, have actual or legal control over any other corporation or  
     LLC , or is the business actually or legally controlled by any other corporation or LLC, whether such  
     control is effected through stock ownership or in any other manner?        YES        NO          
                                                           
     (A)  If yes, state the extent and manner of such control, the nature of the business, and the name and address  
     of such corporation(s) or LLC(s) together with the names and addresses of the officers and directors of each  
     such corporation or LLC. 
                                                           



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WLD-33 (4/18) 
 4.    List names of brewers or legally authorized agents, distributors or importers of malt beverages who  
        have designated a geographic territory within which you may sell their malt beverage products to  
        qualified liquor licensees or permitees. (If additional space is required, complete on a separate  
        piece of paper and attach).  
  
      Please attach a completed Territorial Coverage form for each brewer / importer.        
  
  BREWER/IMPORTER               BRANDS               TERRITORIAL COVERAGE               DATE OF CERTIFICATION 
                                                                           
State law requires all malt beverage described above be available for purchase and delivery to all liquor licensees or malt 
beverage permittees within the territory designated. 
 
 5.  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.) 
                                                              
6.  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. 
 



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 WLD-33 (4/18) 
                                                                                                                 Do you hold       Have you been 
                                                                                                                 any interest,     Convicted of a 
                                                                                                                 directly or            Violation 
                                                                                                                 indirectly, in    Relating to the 
                                    DO NOT LIST PO                                                               any liquor             sale or 
                                     BOXES                                                                       license or        manufacture of 
                                    Residence Address,    Residence                    No of years               permit issued in  Alcoholic Liquor 
                         Date of    Street, City, State &  Phone                        in corp or   % of Stock  the State of           or Malt 
  True and Correct Name  Birth         Zip                 Number                        LLC          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.) 
  
                                        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) 
           
                                                                                          Please mail $250.00 check, application and   
                        (Title)                                                              a copy of your Federal Basic Permit to:     
                         
                                                                                                     Wyoming Liquor Division 
                                                                                                     Compliance 
                                                                                                     6601 Campstool Rd. 
                                                                                                     Cheyenne, WY  82002-0110 






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