Liquor Licensing & Inspection

Bureau of Alcoholic Beverages Division of Liquor Licensing & Enforcement 8 State House Station Augusta, ME 04333-0008 Tel: (207) 624-7220 Fax: (207) 287-3434

Office Use Only APPLICATION FOR Date Received: ______PERMIT TO PURCHASE, IMPORT AND Basic Permit Issue Date: ______Basic Permit Number: ______TRANSPORT ALCOHOL

Date: ______Application is hereby made by: (Name of Applicant): ______, the holder of Basic Permit No. ______, for Permit to Purchase, Import and Transport the alcohol hereinafter described, and to purchase same from: (Name of Vendor) ______, whose business address is (Street & Number) ______, (Town/City)______, (State) ______: said alcohol to be delivered to and stored on the premises covered by the above mentioned Basic Permit issued to the undersigned date of ______, 20 ______, for use solely for the following legitimate use and purpose:______Tax Paid? (Applicant will indicate which ڤ Tax Free or ڤ :Kind of alcohol to be purchased imported and transported – See Instructions) ______Name of alcohol to be purchased, imported and transported, as known to the trade. ______Exact quantity of alcohol to be purchased, imported and transported immediately. ______The actual management of the business and operations to be carried on under the permit will be under the direct charge and supervision of: ______Whose business address is: ______

The undersigned applicant swears or affirms that Basic Permit No. ______, above referred to, was issued to the applicant on the date hereinbefore stated and is now in full force and effect; that the applicant is qualified under the laws of the State of Maine and the rules and regulations of the Commissioner pertaining to alcohol, to purchase, import and transport the alcohol hereinbefore described; and that the applicant will observe and conform to all the provisions, stipulations and conditions of said Basic Permit and any permit which may be issued hereon.

Signed: ______Individual ______Partnership or Corporate Name

______Member of Partnership or Corporation

Application approved this ______day of ______, 20 ______

By: ______Commissioner of Liquor Licensing & Inspection

INSTRUCTIONS Legitimate users of Tax Free Alcohol, such as Schools, Colleges, State Institutions and Hospitals, must first apply for and secure a Tax Free Permit from the Untied States Treasury Department, Bureau of Internal Revenue, Alcohol, & Tobacco Tax Division, John F. Kennedy Building, Boston, Massachusetts. PerPurImpTransAlcApp 2/14