STATE OF CALIFORNIA
BOARD OF EQUALIZATION
Revenue and Taxation Code Section 30165.1
Applicants for a Distributor's License under section 30140 of the Revenue and Taxation Code must certify they will fully comply with section 30165.1 of the Revenue and Taxation Code (copy enclosed). Your application will not be processed or approved if it is incomplete or submitted without the proper certification.
The distributor identified below certifies that it will comply fully with Revenue & Taxation Code section 30165.1 and acknowledges and understands that any person who makes this certification and asserts the truth of any material matter that he or she knows to be false is guilty of a misdemeanor punishable by imprisonment of up to one year in county jail, or a fine of not more than $1,000, or both the fine and imprisonment. Note: This form must be signed by an owner, partner, corporate officer, LLC member or manager, or by an authorized agent. For a partnership, attach authorization signed by all general partners; for a corporation, attach corporate resolution; and for a LLC, attach articles of organization which authorize the individual who signs below to make this certification. If signed by an authorized agent, a properly completed power of attorney must be attached to this certification.
NAME OF PERSON AUTHORIZED TO SIGN (typed or printed)
SIGNATURE OF PERSON AUTHORIZED TO SIGN