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If a field is not applicable please type N/A in that field.
Primary Source Registration Number
Doing Business As
State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVTWAWIWVWY Zip
Telephone (including area code)
Name a PERSON located in INDIANA you wish to serve as your contact with the Indiana Alcohol & Tobacco Commission:
Telephone Number (including area code)
Our company is classified as the following by the TTB (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 email@example.com. 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.
Please declare all wholesalers in the State of Indiana your company ships to:
The (company) through (company officer) agrees to:
If this Registration is being submitted by a Compliance Agency on behalf of the Company, please provide the following:
Compliance Agency Name
By submitting this registration, you consent that all actions or proceedings arising in connection with this registration shall be tried and litigated exclusively in the State and Federal Courts located in the County of Marion, State of Indiana.
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