PLCB-1855 6/07
COMMONWEALTH OF PENNSYLVANIA
APPLICATION FOR BUREAU OF LICENSING
PENNSYLVANIA REGISTRATION OF AGENT (BROKER)
LIQUOR CONTROL BOARD
(NO DUPLICATE REQUIRED)
Date _____________________
The undersigned holder of License or Permit No. _________________ issued by the Pennsylvania Liquor Control Board,
hereby applies for the registration of the following Importer as its agent for the year ending December 31, ___________ .
1. AGENT (BROKER) – PROVIDE NAME OF IMPORTER PHONE NO. LICENSE/PERMIT NO.
( )
2. ADDRESS OF IMPORTER (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) (COUNTY) (STATE) (ZIP)
3. NAME OF VENDOR PHONE NO.
( )
4. ADDRESS (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) (COUNTY) (STATE) (ZIP)
5. VENDOR’S SIGNATURE TITLE
INSTRUCTIONS
1. Provide name of licensed Importer which will serve as your agent in Pennsylvania.
2. Each application must be accompanied by a certified check or money order in the amount of $65.00.