CRF-013 (Rev

ATT-6 (Rev. 7/08) STATE ALCOHOL LICENSE APPLICATION WHOLESALER / MANUFACTURER / SHIPPER PRINT OR TYPE APPLICATION IDENTIFICATION SECTION 1. If Issued a Georgia State Taxpayer Identifier (STI) Number, Enter here: 1a. Georgia Sales Tax Number 2. Legal Business Name 2a. DBA OR Trade Name 3. Physical Location Address (Do not enter Post Office Box) 4. City County State Zip Code+4 Phone Fax ( ) ( ) 5. Email Web Address 6. Proprietorship Partnership Corporation LLC LP LLP ALCOHOL INFORMATION SECTION 7. License Year Application Submitted For: 8. Name of Licensee: 9. If Licensee is not a Proprietorship Provide Name and Address of Registered Agent: Name : Address : 10. Sales Tax Number 11. Withholding Tax Number 12. To which local governments will you pay ad valorem tax? 13. Which local governments will be issuing your alcohol license(s)? Name(s) City or County IN-STATE APPLICANT DO YOU COMPLY WITH THE DISTANCE REQUIREMENTS OF O.C.G.A. 3-3-21 AND REGULATION 560-2-2-.32 BELOW? +100.00 Investigation Fee +100.00 Investigation Fee TYPE OF LICENSE (Check only onemajor category that applies) WHOLESALER IMPORTER BROKER + $100.00 Investigation Fee Beer Fee $500.00 Wine Fee $500.00
Liquor Fee $1,000.00 Beer Fee $500.00
Wine Fee $500.00
Liquor- Fee $1,000.00 Beer Fee $50.00 Wine Fee $50.00
Liquor Fee $100.00 14. When or will you begin selling alcohol beverages for which this application is made? FEE SECTION DISTILLERY-LIQUOR- Fee $1,000.00 FARM WINERY-Fee $50.00
MANUFACTURER (PRODUCER)-WINE-Fee $1,000.00 BREWERY-Fee $1,000.00
BREWPUB- Fee $1,000.00
NON-BEVERAGE ALCOHOL MANUFACTURER- No Fee
NON-BEVERAGE ALCOHOL IMPORTER- No Fee
WINERY SPECIAL ORDER SHIPPING-Fee $50.00 TYPE OF LICENSE (Check only one major category that applies) Beer No Fee
Wine No Fee WINERY SPECIAL ORDER SHIPPING FOREIGN PRODUCER Liquor Fee $100.00 (See note below) NOTE: The registration fee for Foreign Producer is $100.00 which covers the registration up to ten brands. Additional brands in excess of ten are $10.00 for each additional brand. Wine Fee $ 50.00 OUT-OF-STATE APPLICANT GEORGIA DEPARTMENT OF REVENUE ALCOHOL AND TOBACCO DIVISION P.O. BOX 49728 ATLANTA, GA 30359 (404) 417-4870 No Person knowingly and intentionally may sell or offer to sell: A. Any liquor within 600 feet of any school ground. B. Any malt beverages or wine within 300 feet of any shcool ground. C. Any liquor within 300 feet of any church building. D. Any liquor, malt beverages and/or wine within 300 feet of any government owned and opperated alcohol treatment center. Yes No 3a. Business Address OFFICE USE ONLY Total Amount Received $ STATE ALCOHOL LICENSE NUMBER 15. } + $100.00 Investigation Fee For Each Application. NOTE: $100.00 Investigation fee is not required for Winery Special Order Shipping. FOREIGN IMPORTER Print Clear ATT-6 (Rev. 7/08) DO YOU COMPLY WITH THE REQUIREMENTS OF REGULATION 560-2-2.38? Neither a manufacturer, producer, shipper, importer, or broker, whether licensed in this State, or not, nor any of his employees or members of such manufacturers, producers shippers, importers or broker's immediate family shall have, own or enjoy any ownership interest in , or partnership arrangement or other business association with the business of any wholesaler, retail dealer or retail consumption dealer licensee. Neither a wholesaler, whether licensed in this State or not, nor any of his employees, or any members of such wholesalers family shall have, own or enjoy any ownership interest in, or partnership arrangement or other business association with the business of any manufacturer, producer, shipper, importer, broker, retail dealer or retail consumption dealer; provided nothing herein shall prohibit such persons from owning stock in such firms when such firms stock is publicly traded on a national exchange or over the counter. Neither a retail dealer or retail consumption dealer, whether licensed in this State or not, nor any of his employees or members of such retail dealers or retail consumption dealers immediate family shall have, own or enjoy ownership interest in, or partnership arrangement or other business association with the business of any wholesaler, manufacturer, producer, shipper, importer or broker. THIS APPLICATION HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. I DECLARE, UNDER PENALTY OF PERJURY, THAT THIS APPLICATION HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS TRUE, CORRECT, AND COMPLETE. ____________________________________ ____________________________________ _____________________ Signature Title Date (Must be signed by licensee. If the licensee is a corporation, must be signed by an officer of the corporation. Stamped signature is not acceptable) SIGNATURE SECTION 16. Yes No Print Clear

Comments