Primary Source Registration

If a field is not applicable please type N/A in that field.

Primary Source Registration Number

Company Name

Doing Business As



State Zip

Mailing Address


State Zip

Company website

Company representative

Email address

Telephone (including area code)

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


Email Address

Telephone Number (including area code)

Our company is classified as the following by the TTB (Check all that apply):

Liquor Importer
Beer Importer
Wine Importer
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 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:

  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


Company Website

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.