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Indiana Alcohol & Tobacco Commission

ATC > Alcohol Resources > Alcohol Beverage Applications & Forms > Primary Source Renewal Form Primary Source Renewal Form

Indiana Primary Source Number

Company Name

DBA

Address

City
State Zip

Company website

Company representative

Email address

Phone
(including area code)

Name a person located in Indiana you wish to serve as your contact with the Indiana Alcohol & Tobacco Commission:

Name

Phone


Home State Alcoholic Beverage Permit Number

US Department of Treasury Alcohol Tax Number

The (company) through (company officer) agrees to:

  1. Observe all Indiana laws, rules, and regulations promulgated by the Indiana Alcohol & Tobacco Commission and the Indiana Department of Revenue.
  2. Forward to the Indiana Department of Revenue a monthly report and copies of all invoices to Indiana wholesalers
  3. Submit any changes in this registration statement to the Indiana Alcohol & Tobacco Commission.
  4. Consent to examination of books and records pertaining to Indiana permittees.
  5. Submit all point-of-sale advertising materials and product promotional material to the ATC for approval, revision, or rejection.
  6. Obtain a Salesman permit for any employee of your company who procures or seeks to procure an order, bargain, contract, or agreement for the sale, or for the delivery, or for the transportation of alcoholic beverages, or who is engaged in promoting the sale of alcoholic beverages, or in promoting the business of any person engaged in the manufacturing, selling, delivery or transportation of alcoholic beverages for sale or delivery, whether the seller resides within the State of Indiana and sells to buyers either within or without Indiana.
  7. That if accepting orders over the internet for the shipment of wine to Indiana to:
    1. Obtain an Internet Salesman Permit from the Commission (call 317-232-2430 and ask for a Salesman Permit processor).
    2. Ship all products through a licensed Indiana wholesaler.

If this Registration is being submitted by a Compliance Agency on behalf of the Company, please provide the following:

Compliance Agency Name

Compliance Agent

Email Address

Phone (including area code)