TTB F 5100.24: Application for Basic Permit Under the Federal Alcohol Administration Act

Enter the full name and premises address under 1. FULL NAME AND PREMISES ADDRESS and the employer identification number (EIN) under 3. EMPLOYER IDENTIFICATION NUMBER (EIN); a Social Security number is not acceptable.

You need to have this number for your business even if you do not have any employees; to obtain an EIN, file Form SS-4 with the Internal Revenue Service.

Enter the operating name (DBA), if any, under 4.

Enter the TELEPHONE NUMBER; enter the state in which organized for Corporations and Limited Liability Companies (LLC); enter the mailing address under 2. MAILING ADDRESS if different from premises address, and the labeling trade name(s), if any, under 5.

6. BUSINESS(ES) TO BE CONDUCTED AT PREMISES ADDRESS: check applicable boxes.

Under a. DISTILLED SPIRITS PLANT (BEVERAGE), check distilling distilled spirits, warehousing and bottling distilled spirits, or processing (rectifying) distilled spirits and wine; under c. IMPORTING INTO THE UNITED STATES, check distilled spirits, wine or malt beverages.

Under b. BONDED WINE PREMISES, check producing and blending wine or blending wine; under d. PURCHASING FOR RESALE AT WHOLESALE, check distilled spirits, wine or malt beverages.

7. REASON FOR THE APPLICATION (use date format MM/DD/YYYY): for a. NEW BUSINESS, enter the anticipated start date; for b. CHANGE IN CONTROL (Actual or legal), enter the date of change and submit Basic Permit(s) with this application; for c. CHANGE IN OWNERSHIP, enter the date of change and the name, address, and permit number(s) of predecessor.

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.

Enter the NAME, the TITLE, the % VOTING/STOCK/INTEREST (If applicable), the INVESTMENT IN BUSINESS (Item 6) and the SOURCE OF FUNDS INVESTED (savings, loans, gift or specify other).

9. COMPLETE FOR EACH PERSON LISTED IN ITEM 8. If applicant is actually or legally controlled by persons or businesses not identified above, provide on a separate sheet information (as specified for Item 9) for each person or business and state the extent and manner of the control. Businesses should include their EIN.

Enter a. FULL GIVEN NAME, b. DATE AND PLACE OF BIRTH, c. SOCIAL SECURITY OR EMPLOYER IDENTIFICATION NUMBER and e. OTHER NAMES USED (Maiden name, nicknames, etc.); check MALE or FEMALE.

Next: a. FULL GIVEN NAME, b. DATE AND PLACE OF BIRTH, c. SOCIAL SECURITY OR EMPLOYER IDENTIFICATION NUMBER, e. OTHER NAMES USED (Maiden name, nicknames, etc.), MALE FEMALE.

10. Has the applicant or any person listed for Items 8 or 9 ever been denied a permit, license, or other authorization to engage in any business to manufacture, distribute, import, sell, or use alcohol products (beverage or nonbeverage) by any government agency (Federal, State, local, or foreign) or had such permit, license, or other authorization revoked, suspended, or otherwise terminated? Check YES or NO. YES: State details of each event on a separate sheet.

11. Has the applicant or any person listed for Items 8 or 9 ever been arrested for, charged with, or convicted of any crime under Federal, State, or foreign laws other than traffic violations or convictions that are not felonies under Federal or State law? Check YES or NO.

12. APPLICANT'S SIGNATURE: sole owner, partner, corporate officer, LLC member or manager, or if designated agent, submit TTB F 5000.8.

Enter 13. TITLE OF PERSON SIGNING, 14. DATE and, optional, 15. E-MAIL (INTERNET) ADDRESS.

APPLICANT'S AFFIRMATION. Under penalties of perjury, the applicant declares that the applicant has examined this application, including accompanying statements, and to the best of the applicant's knowledge and belief, it is true, correct, and complete.

The applicant must immediately notify the TTB official with whom this application is filed of any change in ownership, management, or control of the applicant (in the case of a corporation, any change in the officers, directors, or persons holding 10 percent or more of the corporate stock).

The business for which this application is made does not violate the law of the State in which the business will be conducted. In addition, if this application is approved, the applicant will conduct operations within a reasonable period of time and maintain such operations in conformity with Federal law.

COMPLETING AND FILING THIS APPLICATION. Please type or print and complete all items. Write "not applicable" in any item requesting information that does not apply to your business. Items 8 through 11: If this information is on file with TTB, state "On file under (name and TTB permit or registry number or type of pending application)." If you need additional room, use a separate sheet. If your producing or processing operations will be in Puerto Rico, contact the Director, Puerto Rico Operations, for additional requirements. Send this form in duplicate to the appropriate TTB (Alcohol and Tobacco Tax and Trade Bureau) office: Puerto Rico, Ste. 310 Torre Chardon, 350 Carlos Chardon Ave., San Juan, PR 00918-21244; all other states, 550 Main Street, Suite 8970 Cincinnati, OH 45202-3222.