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. |
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. |
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 |