WLD-93 (4/18)                                                                                   
                                          
                                                                           Date Rec’d             /           / 
                                  AUTHORIZATION                            Amount Rec’d        $ 
                                                                           Cash         Recpt #: 
                                 FOR OFF PREMISE 
                                                                           Check        Ck #: 
                                        SALE OF                            Processed by:                  
                                                                           Payment  Processed:         /        / 
 6601 Campstool Road             MICROBREWERY 
                                                                           Control Number:                 
  Cheyenne, Wyoming  82002-0110   PRODUCTS 

                                  APPLICATION 

       MICROBREWERY LICENSE TERM: ______________ through ______________ 

 LICENSE    FEE:     $200.00                                                           

 Applicant:                      
  
 Business Name (DBA):            
  
 Premise Address:                
                                          CITY   STATE                     ZIP 
 Mailing Address:                
                                          CITY   STATE                     ZIP 
 Business Phone:                          Fax Number:   
                                 
 Email Address:                  
                                           
  1.     Are you applying for authorization to sell product off premise?                           YES      NO 
   
  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 Applicant                  Date 
   
                     **$200.00 FEE DUE WITH APPLICATION **