Application For Supplier Representative Permit For Spirituous Liquor printable pdf download

PLEASE

Permit No. ________

Date Issued: _______

ATTACH

North Carolina

Alcoholic Beverage Control Commission

A RECENT

Mailing Address: 4307 Mail Service Center, Raleigh, NC 27699-4307

Location: 400 East Tryon Road, Raleigh, NC 27610

PHOTO

Phone: (919) 779-0700 Fax: (919) 661-5927

Application for

Supplier Representative

Permit for Spirituous Liquor

Application Requirements

A. Include a recent photo

B. Include a Certified Criminal Record Check or a certified copy of a

court record(s) from the last jurisdiction where you have maintained

residence for one year or more. If there is no record, please have the

clerk of the court in the jurisdiction so certify.

C. This form MUST be Notarized (second page)

1. Name of the Supplier you represent

Date of employment: ________________________________________________________________________

2. Territory responsible for: _____________________________________________________________________

3. Name (PRINT):

4. Mailing Address: ___________________________________________________________________________

5. E-mail address (Required): ___________________________________________________________________

6. Phone No: (

) __________________________Driver's License No:_______________________________

7. Social Security No.– LAST FOUR (4) DIGITS. ______________Date of birth: _________________________

8. Address of last place of residence for period of one year or more:

_________________________________________________________________________________________

9. Are you (or your spouse) related to any state or local ABC Board Member or the employees thereof?

____Yes ____No

If yes,

Name, relationship, and their address.

a. _______________________________________________________________________________________

b. _______________________________________________________________________________________

10. Do you now or have you (or your spouse) previously held any type of permit(s) issued by the North Carolina

Alcoholic Beverage Control Commission? If so, for each permit indicate the date and name of the business

licensed, and, if applicable, the reason the permit is no longer held.

a. _______________________________________________________________________________________

b. _______________________________________________________________________________________

Rev 3/7/2014

Application For Supplier Representative Permit For Spirituous Liquor