Application For A Brokerage Permit For Spirituous Liquor
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1
2PLEASE
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
Brokerage
Application for a
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. Include a copy of your Articles of Incorporation or Articles of
Organization (LLC)
D. This form MUST be Notarized (second page)
:
1. Name of Brokerage
Date formed
: _____________________________________________________________________________
2. Territory responsible for
: ___________________________________________________________________
3. Name of Owner (PRINT):
4. Business 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. 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. _______________________________________________________________________________________
9. 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
1
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