Special Distributorship Application - Supplement

Special Distributorship Application – Supplement

This supplemental application is to be submitted by each additional person to be named in, (is a signer of) the contract. Before beginning, click on these links for instructions and a list of required documents to be submitted with your application “Special Distributorship Application Checklist” (Checklist) and “Qualifications of Special Distributors”. The primary contact (signer), must complete the “Special Distributorship Application” (not the Supplement). For a sample contract, click here: “Special Distributorship Agreement-Sample”.

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1. Applicant’s Information
Name*
Physical Address*
Street Address City State ZIP Code
Mailing Address (if different)
Street Address City State ZIP Code
Telephone/Cell Number(s)*
Email Address*
Length of Time You Have Been an Idaho Resident*
Attach Proof of Idaho Residency*
Idaho Code § 23-304. Proof of Idaho residency (valid, state-issued identification and other documents), required. See checklist for specifications.
Drop files here or

Max. file size: 64 MB.
Attach Credit Report (Include Current Credit Score)*
See Checklist for a list of acceptable documents
Drop files here or

Max. file size: 64 MB.
Attach Criminal Background Check*
IDAPA Rule 15.10.01 011. 06. c. An applicant who has been convicted of, or has pleaded guilty to, a felony or a crime of moral turpitude (an element of which is dishonesty or fraud) under the laws of any state, U.S. Territory or protectorate, the District of Columbia, or the United States will not be allowed to operate a Distributing Station.
Click Here for a Criminal Background Check Authorization Form
Do not complete the credit card portion. See Checklist for detailed instructions. Original signature is required; electronic signature is not accepted.
Max. file size: 64 MB.
Total Number of Principals/Partners Applying (in addition to yourself; if none enter NA)*
List All Principals/Partners to be Named in the Contract (in addition to yourself; if none enter NA)*
Number of Hours a Week You Intend to Spend in the Store*
2. Business Information
Liquor-by-the-Drink, Beer, or Wine Licenses (of any type), Currently Held by You and/or the Business Named Herein (List all; If none, enter NA)*
Note whether You and/or the Business Named Herein Has Ever Had a Liquor License (of any type) Revoked or Suspended (if "yes", explain; If "no", enter NA)*
- Yes
- No
Explain:*
3. Store Information
Store Name/DBA (known to the public as)*
Physical Address*
Street Address City State ZIP Code
4. Idaho Codes and Rules
It is recommended that you be familiarized with Idaho liquor codes and rules:
Idaho Liquor Laws: https://legislature.idaho.gov/statutesrules/idstat/Title23.
IDAPA RULES: https://adminrules.idaho.gov/rules/current/15/151001.pdf.

These include but are not limited to:

     • IDAPA Rule 15.10.01 011. 06. d. An applicant may not be a Close Relative of, or have a partnership or other close business relationship with any person employed by the Division who has the responsibility for establishing, approving, or influencing policies of the Division.

     • IDAPA Rule 15.10.01 011. 06. e. An applicant may be a spouse, child, employee, blood relative, relative through marriage, or business associate of the retiring or deceased Distributor.

     • IDAPA Rule 15.10.01 011. 07 d. The Distributor shall not hold a partisan state elective political office. He cannot be a Close Relative of, or be in a business partnership with a person in a partisan state elective Political Office.
Do you meet the qualifications for a Distributorship based on Idaho Code Title 23, and Idaho State Liquor Division IDAPA Rule 15.10.01 011. 06. d., IDAPA Rule 15.10.01 011. 06. e., IDAPA Rule 15.10.01 011. 07 d.?*
- Yes
- No
5. Signature
I do hereby attest that I have the authority to sign legally binding contracts on behalf of the business entity named herein. I have read and understand the Idaho liquor laws and IDAPA rules, have not been convicted of or pleaded guilty to a felony or a crime of moral turpitude, have a reputation of “probity, temperance and integrity”, will comply with federal, state, county and local laws, regulations, and Idaho State Liquor Division rules and policies in operating a liquor distributing station, consent to criminal background and credit checks, am presently an Idaho resident for a minimum of six (6) months, and acknowledge that the selection of Special Distributors (Contractors) is at the sole discretion of the Director or his appointed representatives. I certify that all information provided in the application and all required documents are accurate to the best of my knowledge.

By submitting this application, you are acknowledging that the electronic signature below, is intended to have the same force and effect as your manual signature.

In case of any conflict between the terms or statements herein and any regulations, laws, codes, State or Division policies, the regulations, laws, codes or policies prevail.
E-Signature*
Name Business Name Date
Signature page must accompany application. If alternate arrangements are needed for submitting this application or any of the required documents, contact one of the ISLD representatives listed on the Checklist, for permission and instructions.

Special Distributorship Application – Supplement

1. Applicant’s Information

2. Business Information

3. Store Information

4. Idaho Codes and Rules

5. Signature

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