WLD-612 (7/2012)
STATE OF WYOMING
Department of Revenue
Liquor Division
6601 Campstool Road
Cheyenne, WY 82002-0110
(307) 777-6449
Limited Transportation Liquor License Application
Type of Business: Railroad
Bus
Limousine
____________(Other)
Type of License Railroad: Annual (Fee $250.00) 24Hr (Fee $25.00)
Applied for: Charter: Annual (Fee $250.00) 24Hr (Fee $25.00)
Effective: From: / / To: / /
Applicant: D/B/A:
Contact Person: Phone: ( ) -
Company Location: City: State: Zip:
Mailing Address: City: State: Zip:
Vehicle License Plate Number: State:
FILING AS (CHOOSE ONLY ONE)
INDIVIDUAL PARTNERSHIP CORPORATION LLC LLP
NOTE: Individual and Partnership filers must be domiciled residents of Wyoming for at least one year and not claimed
residence in any other state in the last twelve months, and provide personal information in table below.
Applicants Legal Name Date of DO NOT LIST PO BOXES Residence Phone Have you been a Have you Have you been
Birth Residence Address, Street, Number DOMICILED resident for been Convicted of a
City, State & Zip at least 1 year and not Convicted of a Violation Relating
claimed residence in any Felony to Alcoholic Liquor
other statein the last year? Violation? or Malt Beverages?
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 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.
Applicants Legal Name Date of DO NOT LIST PO BOXES Residence Phone For corp or For corp or Have you Have you been
Birth Residence Address, Street, Number LLC. No of LLC. been Convicted of a
City, State & Zip years in corp % of Stock Convicted of a Violation Relating
or LLC Held Felony to Alcoholic Liquor
Violation? or Malt Beverages?
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.)
By filing this application, I agree to operate in Wyoming under the requirements of W.S.12-2-202 and all other applicable Wyoming
laws and rules, and to file required sales tax reporting documents and taxes.
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 office or LLC/LLP member.
VERIFICATION OF APPLICATION
(Requires signatures by ALL Individuals, ALL Partners, ONE (1) LLC Member, TWO (2) Corporate Officers or Directors, except
that if all the stock of the corporation is owned by ONE (1) individual then that individual may sign and verify the application upon
his oath, or TWO (2) Club Officers.) W.S.12-4-102(b)
Under penalty of perjury, and the possible revocation or cancellation of the license, I swear the above stated facts, are true and
accurate.
Dated this _______ day of _______________, _______.
________________________________________________
Applicant
For Liquor Division Use Only
Agent: ________________________________________________
Date: _ Applicant
Check: