APPLICATION FOR 24 HR MALT BEVERAGE PERMIT
Licensing Authority:
Name of Event:
Permit From: / / To: / / Local Permit Number:
Number of Days Permitted: Fee Per Day: Total Fee:
Applicant: D/B/A:
Contact Person: Phone Number:
Address:
City: State: Zip Code:
Mailing Address:
Business Phone: Residence Phone:
Location of Sales:
Applicants that are receiving anything of value (i.e. money, good and/or services) from any industry
representative must answer the following:
As an applicant for a 24 hour malt beverage permit, are you:
A nonprofit corporation organized under the laws of this state?
Qualified as a tax exempt organization under the Internal Revenue Code?
And have been in continuous operation for not less than (2) years?
Yes: No:
Yes: No:
Yes: No:
By filing this application, I agree to operate in Wyoming under the requirements of W.S. 12-4-502 and all other
applicable Wyoming laws and rules, and to file required sales tax reporting documents and taxes.
By signing this application, I acknowledge for (Business Name)
that all of the information provided is true and correct, and that I agree to meet the Wyoming operating
conditions specified above. This application must be signed by an owner, partner, corporate office or LLC/LLP
member.
Under penalty of perjury, and the possible revocation or cancellation of the license, I swear the above stated
facts, are true and accurate.
Dated this day of , . Applicant:
Applicant:
Signature of Licensing Authority Official
Title Date
