Form Ttb F 5100.24 - Application For Basic Permit Under The Federal Alcohol Administration Act

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OMB NO. 1513-0018 (08/31/2011)
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
APPLICATION FOR BASIC PERMIT UNDER THE FEDERAL ALCOHOL ADMINISTRATION ACT
1. FULL NAME AND PREMISES ADDRESS
3. EMPLOYER IDENTIFICATION NUMBER (EIN)
(Social Security number is not acceptable)
4. OPERATING NAME (DBA), if an y
TELEPHONE NUMBER (
)
State in which organized for Corporations and Limited Liability Companies (LLC):
2. MAILING ADDRESS (If different from premises address)
5. LABELING TRADE NAME(S), if an y
6. BUSINESS(ES) TO BE CONDUCTED AT PREMISES ADDRESS (Check applicable boxes)
a.
DISTILLED SPIRITS PLANT (BEVERAGE)
c.
IMPORTING INTO THE UNITED STATES
DISTILLING
DISTILLED SPIRITS
WAREHOUSING AND BOTTLING DISTILLED SPIRITS
WINE
PROCESSING (RECTIFYING) DISTILLED SPIRITS AND WINE
MALT BEVERAGES
b.
BONDED WINE PREMISES
d.
PURCHASING FOR RESALE AT WHOLESALE
PRODUCING AND BLENDING WINE
DISTILLED SPIRITS
BLENDING WINE
WINE
MALT BEVERAGES
or while so engaged, sell, off er, or deliver for sale, contract to sell, or ship in interstate or f oreign commerce the alcoholic beverages so distilled,
produced, rectified, blended or bottled, warehoused and bottled, impor ted, or purchased for resale at wholesale.
(use date format MM/DD/YYYY)
7. REASON FOR THE APPLICATION
a.
NEW BUSINESS
c.
CHANGE IN OWNERSHIP
Anticipated start date ___________
Date of Change _______________
Name, address, and permit number(s) of predecessor
b.
CHANGE IN CONTROL (Actual or legal)
Submit Basic Permit(s) with this application.
Date of Change ______________
8. OWNER INFORMATION (List sole owner, all general parties, LLC members/managers, corporate officers and directors, and shareholders with more
than 10% voting stock. Each listed person must also furnish the information in Item 9.)
SOURCE OF FUNDS INVESTED
% VOTING/STOCK/INTEREST
INVESTMENT IN
(savings, loans, gift, or specify
% VOTING/STOCK/INTEREST
INVESTMENT IN
SOURCE OF FUND,S INVESTED
NAME
TITLE
TITLE
NAME
(If applicable)
BUSINESS (Item 6)
other & financial institution
(If applicable)
BUSINESS (Item 6)
(savings, loans, gift or specify other)
name, city & state)
IF APPLICANT IS ACTUALLY OR LEGALLY CONTROLLED BY PERSONS OR B USINESSES NOT IDENTIFIED ABOVE, PROVIDE ON A SEPARATE
SHEET INFORMATION (as specified f or Item 9) FOR EACH PERSON OR B USINESS AND STATE THE EXTENT AND MANNER OF THE CONTROL.
BUSINESSES SHOULD INCLUDE THEIR EIN.
9. COMPLETE FOR EACH PERSON LISTED IN ITEM 8.
a. FULL GIVEN NAME
b. DATE AND PLA CE OF
c. SOCIAL SECURITY OR EMPLO YER
d. ARE YOU A U .S. CITIZEN?
BIRTH
IDENTIFICATION NUMBER
YES
NO
e.
f. OTHER NAMES USED (Maiden name, nicknames, etc.)
MALE
FEMALE
g. RESIDENCE(S) OVER THE LAST FIVE YEARS
TTB F 5100.24 (
)
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