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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

Complete only those fields that are being updated or changed.

Name of Company

DBA

Address

City State Zip

Email address

Company website

Name the person with your company you wish to serve as your contact with the Indiana Alcohol & Tobacco Commission and his or her telephone number (including area code):

Name

Phone

Fax

Name a person located in Indiana you wish to serve as your contact with the Indiana Alcohol & Tobacco Commission and his or her telephone number (including area code):

Name

Phone

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
Owner of a Marketable Alcoholic Beverage

Home State Alcoholic Beverage Permit Number

US Department of Treasury Alcohol Tax Number

Other Notes