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Indiana Alcohol & Tobacco Commission

ATC > Alcohol Resources > Alcohol Beverage Applications & Forms > Primary Source Update Information Form Primary Source Update Information Form

Indiana Primary Source Number (Required)

Company Representative (Required)

Email Address (Required)

Telephone Number (including area code) (Required)

Complete ONLY those fields that are being updated or changed.

Company Name

Doing Business As

Address

City

State Zip

Mailing Address

City

State Zip

Company website

Company Representative 

Email address

Telephone Number (including area code) 

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

Name

Email Address

Telephone Number (including area code)

Our company is one of the following or an authorized agent for one of the following (Check all that apply):

Distiller
Rectifier
Bottler
Liquor Importer
Beer Importer
Wine Importer
Vintner
Winery
Brewer
Wholesaler/Owner of a Marketable Alcoholic Beverage

Home State Alcoholic Beverage Permit Number(s)

Federal Basic Permit Number(s)

PLEASE EMAIL COPIES OF THESE PERMITS TO psource@atc.in.gov. Your registration cannot be processed without these permits. If you selected Wholesaler/Owner of a Marketable Alcoholic Beverage, a letter from the manufacturer stating you have the right to distribute the product here in Indiana is required.

Other Notes

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

Compliance Agency Name

Compliance Agent

Email Address

Telephone Number (including area code)

Company Website