
Applicant Name Federal Basic Permit Number
Trade Name Telephone Number
Mailing Address (Street Number, City, State, ZIP)
Colorado Wholesaler(s) Product(s) will be shipped to
For Sole
Source
Applications:
See instructions on back page
For New Product Registrations: See instructions on back page
Sole Source Registration 2240-100 (999) $100 x
_____________________ Total Fee: _________________________
Product Registration 2290-100 (999) $5.00 x _____________________
Total Fee: _________________________
DR 8440 (12/00)
Name of Importer Colorado License Number Period
Sole Source Registration ............................ 2240-100 (999) $100 x _________
Product Registration.................................... 2290-100 (999) $5.00 x _________ TOTAL
DR 8440 (12/00)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN ST
DENVER CO 80261
(303) 205-2300
ALL IMPORTERS AND MANUFACTURERS FILL OUT THIS SECTION
Name of Primary Source Telephone Number Federal Permit Number
Address of Primary Source (Street Number, Box Number, Rte., City, State, ZIP)
NEW PRODUCT REGISTRATION
Product Name
1.
2.
3.
4.
5.
6.
Colorado License Number
SOLE SOURCE APPLICATIONS
COLORADO LICENSED
IMPORTERS/MANUFACTURERS
Sole Source of Supply/Brand Registration Form
DO NOT WRITE IN THIS SPACE
COLORADO LICENSED
IMPORTERS/MANUFACTURERS
Sole Source of Supply/Brand Registration Form
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