WLD-093  (4/15) 
                            DEPARTMENT OF REVENUE 
                                                                           Rec'd application:          
  NEW                                   LIQUOR DIVISION                   Rec'd cash/check:           
  RENEWAL                               6601 Campstool Road               Reviewed by:                
  Fee: $200.00                           Cheyenne, WY 82002 
                                                                      
                APPLICATION for AUTHORIZATION FOR OFF PREMISE SALE  
                            OF MICROBREWERY PRODUCTS 
                                                                      
                Microbrewery Permit Term:_____/_____/_____/ through_____/_____/_____ 
                                                                      
Microbrewery Permit Holder:______________________________________________________ 
 
Business Name DBA: ___________________________________________________________ 
                                         
 RENEWAL         
Premise         Address:  ______________________________________________________________ 
 
Mailing Address:  _______________________________________________________________ 
 
Business Phone: ______________________                               
 
Are you applying for authorization to sell product off premise?  YES         NO  
If answered YES, complete the following information: 
 
Applicant is requesting authorization from the Liquor Division to sell microbrewery products off premise 
through the following licensed wholesale malt beverage distributors: 
 
 Distributor               Brands                                      Assigned Territory(ies) 

I  have  read  and  understand  the  laws  and  rules  of  the  State  of  Wyoming  regarding  the  sale  of 
microbrewery products off premise.  I understand that violation of those laws and rules may constitute 
denial, suspension or revocation of my off premise authorization. 
 
Signature of Microbrewer or Authorized Agent                                                    Date 
 
                          **$200.00 FEE DUE WITH APPLICATION ** 
 
RETURN APPLICATION TO:  Wyoming Liquor Division 
                                                 6601 Campstool Road 
                                                                          Payment Processed: _____/_____/_____ 
                                                 Cheyenne, WY 82002                                               
                                                                          Control Number: __________________