Beer & Wine License Application

Business Name:
Street Address:
City State Zip Code Phone

Mailing Address (if different):
City State Zip Code Phone

Date established:     Retail Sales: or Consumption on Premises:

Business Owner Name:
Address / PO Box:
City, State, Zip
Phone:     Emergency Phone:

Manager/Contact Person Name (If different):
Address / PO Box:
City, State, Zip
Phone:     Emergency Phone:

Please attach a copy of your Idaho State and Jefferson County permits.
Idaho State permit:
Jefferson County permit:

Security Code