WLD-29 (4/18) 
                             
                                          Manufacturer/Rectifier           Date Rec’d                             /           / 
                                                                           Amount Rec’d
                                          or Importer License                                           $ 
                                                                           Cash                        Recpt #: 
                                           Application 
                                                                           Check                       Ck #: 
                                                      License fee: $250.00 Processed by:                              
6601 Campstool Road                                                        Payment  Processed:                       /        / 
Cheyenne, Wyoming 82002-0110                        LICENSING TERM:        Control Number:                            
                                                      
                             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 (4/18) 
  
 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 least 1 indirectly, in   Relating to the 
                                                                           year and not claimed    any liquor       sale or 
                                                                           residence in any        license or       manufacture 
                                 DO NOT LIST PO BOXES                      other State in the last permit issued in of Alcoholic 
                         Date of  Residence Address, Street,    Residence     year?                the State of     Liquor or Malt 
 True and Correct Name    Birth    City, State & Zip             Phone                             Wyoming?         Beverages? 
                                                                Number 
                                                                           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 
                                                                                                   directly or      Violation 
                                                                                                   indirectly, in   Relating to the 
                                                                                                   any liquor       sale or 
                            DO NOT LIST PO                       No of                             license or       manufacture 
                                 BOXES               Residence  years in                           permit issued in of Alcoholic 
  True and       Date of    Residence Address,       Phone      corp or                            the State of     Liquor or Malt 
 Correct Name    Birth    Street, City, 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 (4/18) 
  
 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) 
           
                                                                                       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