Retail Package Tasting Event Business Name * Business Address * Business Address Business Address Business Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Date of Event * Event Start Time (not to exceed 4 hours) * 121234567891011 : 0030 AMPM Event End Time * 121234567891011 : 0030 AMPM Type of Alcohol Provided at Event (only one type per event) * Malt Beverage Wine Distilled Spirits Staff Contact Name * Staff Contact Name First First Last Last Staff Contact Phone Number * Staff Contact Email * Signature * Clear Date * If you are human, leave this field blank. Submit
