Form TTB F 5100.24 TTB F 5100.24 Application for Basic Permit under the Federal Alcohol A

OMB NO. 1513-0018 (10/31/2014)

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

1.

APPLICATION FOR BASIC PERMIT UNDER THE FEDERAL ALCOHOL ADMINISTRATION ACT

FULL NAME AND PREMISES ADDRESS

TELEPHONE NUMBER (
)
State in which organized for Corporations and Limited Liability Companies (LLC):
2. MAILING ADDRESS (If different from premises address)

6.

3.

EMPLOYER IDENTIFICATION NUMBER (EIN)
(Social Security number is not acceptable)

4.

OPERATING NAME (DBA), if an y

5.

LABELING TRADE NAME(S), if an y

BUSINESS(ES) TO BE CONDUCTED AT PREMISES ADDRESS (Check applicable boxes)
a.

DISTILLED SPIRITS PLANT (BEVERAGE)
DISTILLING
WAREHOUSING AND BOTTLING DISTILLED SPIRITS
PROCESSING (RECTIFYING) DISTILLED SPIRITS AND WINE

c.

IMPORTING INTO THE UNITED STATES
DISTILLED SPIRITS
WINE
MALT BEVERAGES

b.

BONDED WINE PREMISES
PRODUCING AND BLENDING WINE
BLENDING WINE

d.

PURCHASING FOR RESALE AT WHOLESALE
DISTILLED SPIRITS
WINE
MALT BEVERAGES

or while so engaged, sell, off er, or deliver for sale, contract to sell, or ship in interstate or IRreign commerce the alcoholic beverages so distilled,
produced, rectified, blended or bottled, warehoused and bottled, impor ted, or purchased for resale at wholesale.
7.

REASON FOR THE APPLICATION (use date format MM/DD/YYYY)
a.
NEW BUSINESS
Anticipated start date ___________
b.

8.

c.

CHANGE IN OWNERSHIP
Date of Change _______________
Name, address, and permit number(s) of predecessor

CHANGE IN CONTROL (Actual or legal)
Submit Basic Permit(s) with this application.
Date of Change ______________

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.)
NAME
NAME

TITLE
TITLE

% VOTING/STOCK/INTEREST

% VOTING/STOCK/INTEREST
(If applicable)
(If applicable)

INVESTMENT IN
INVESTMENT IN
BUSINESS (Item 6)

BUSINESS (Item 6)

SOURCE OF FUNDS INVESTED
(savings,
gift, or
specify
SOURCEloans,
OF FUND,S
INVESTED
& financial
other
(savings,
loans, giftinstitution
or specify other)
name, city & state)

IF APPLICANT IS ACTUALLY OR LEGALLY CONTROLLED BY PERSONS OR B8SINESSES NOT IDENTIFIED ABOVE, PROVIDE ON A SEPARATE
SHEET INFORMATION (as specified f or Item 9) FOR EACH PERSON OR B8SINESS 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 PL$&E OF
c. SOCIAL SECURITY OR EMPLO<(R d. ARE YOU A U .S. CITIZEN?
BIRTH
IDENTIFICATION NUMBER
YES
NO
e.
MALE

FEMALE

f. OTHER NAMES USED (Maiden name, nicknames, etc.)

g. RESIDENCE(S) OVER THE LAST FIVE YEARS

TTB F 5100.24 ()

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a. FULL GIVEN NAME

e.

b. DATE AND PL$&E OF
BIRTH

c. SOCIAL SECURITY OREMPLOYER
IDENTIFICATION NUMBER

d. ARE YOU A U .S. CITIZEN?
YES

NO

f. OTHER NAMES USED (Maiden name, nicknames, etc.)
MALE

FEMALE

g. RESIDENCE(S) OVER THE LAST FIVE YEARS

a. FULL GIVEN NAME

e.

b. DATE AND PLA&E OF
BIRTH

c. SOCIAL SECURITY OR EMPLOFile Typeapplication/pdfFile TitleTTB F 5100-24SubjectTTB F 5100-24AuthorNancyFile Modified2014-10-22File Created2004-05-12