Date Rec’d             /           / 
                                                          NEW 
                                                                                     Amount Rec’d    $ 
                                                          OUT-OF-STATE 
                                                                                     Check #       
                                                          WINE SHIPPER 
                                                                                     Processed by:               
6601 Campstool Road,                                      LICENSE                    Payment  Processed:         /        / 
Cheyenne, Wyoming 82002 
                                                          APPLICATION                Control Number:              

                                                          LICENSE FEE: $50.00        LICENSE#: ________________ 
                   LICENSE TERM: _____/______/______ through  June 30, ______ 
Applicant:          
D/B/A  :            
                    
Contact Person:                                                             Contact Phone:       
                         
Company Location: 
                         
Mailing Address:      

Business Phone:                                                    Business Fax:  
E-Mail Address:                                                    Website:       
 
                         Is the above information correct?           Yes      No     If No, Please update. 
 
FILING AS (CHOOSE ONLY ONE) 
 
  SOLE PROPRIETOR          PARTNERSHIP                             CORPORATION        LLC                   LLP 
 
If a corporation, LLC or LLP list the full names and residence address of all the officers and directors and of all 
shareholders owning jointly or severally ten percent (10%) or more of the stock of the corporation, LLC or LLP. Use back 
of form if additional space is needed. 
 
                    NAME                                  RESIDENCE ADDRESS           DATE OF BIRTH             % OF STOCK 
                                                                                                             
By filing this application, I agree to operate in Wyoming under the requirements of  W.S.12-2-204 and all other applicable 
Wyoming laws and rules, and to file required monthly tax reporting documents and taxes.  If no shipments occur for any 
given month, the monthly tax report is still required.  I understand that violation of these laws and rules may constitute 
cause for denial, suspension or revocation of my license.  
 
State statute requires a copy of your state’s liquor license.  The 
application can not be processed without the current license.  
 
By signing this application, I acknowledge for __________________________________________(Business Name) that 
all of the information provided is true and correct, and that I agree to meet the Wyoming operating conditions specified 
above.  This application must be signed by an owner, partner, corporate officer or LLC/LLP member. 
 
Signature:  _________________________________  Title:  _______________________    Date:           /          /           
 
Mail completed application, copy of liquor license and a check for $50.00 made out to: 
 
Wyoming Liquor Division 
Attn: Licensing 
6601Campstool Road 
Cheyenne, WY  82002-0110