OMB No. 1512-0092  (01/31/2009)
FOR TTB USE ONLY
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
APPLICATION FOR AND CERTIFICATION/EXEMPTION OF LABEL/BOTTLE APPROVAL
(See Instructions and Paperwork Reduction Act Notice on Back)
TTB ID
05151001000115

1. REP. ID. NO. (If any)
CT
649

OR
14

PART I - APPLICATION
2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
CT-I-336
DSP-AR-3
7. NAME AND ADDRESS OF APPLICANT AS SHOWN ON PLANT REGISTRY, BASIC PERMIT OR BREWER'S NOTICE. INCLUDE APPROVED DBA OR TRADENAME IF USED ON LABEL (Required)

ALLIED DOMECQ SPIRITS, USA, ALLIED DOMECQ SPIRITS & WINE USA, INC.
355 RIVERSIDE AVE

WESTPORT CT 06880

3. SERIAL NUMBER (Required)
051138

4. TYPE OF PRODUCT (Required)
WINE
DISTILLED SPIRITS
MALT BEVERAGE

5. BRAND NAME (Required)
KAHLUA
7a. MAILING ADDRESS, IF DIFFERENT
6. FANCIFUL NAME (If any)
ESPRESSO CLASSICO
8. EMAIL ADDRESS
 
9. FORMULA/SOP NO.
(If any)
678
10. LAB. NO./DATE
(If any)
17. TYPE OF APPLICATION (Check applicable box(es))

a.

CERTIFICATE OF LABEL APPROVAL

b.

CERTIFICATE OF EXEMPTION FROM LABEL APPROVAL
"For sale in _______ only" (Fill in State abbreviation.)

c.

DISTINCTIVE LIQUOR BOTTLE APPROVAL. TOTAL BOTTLE CAPACITY BEFORE CLOSURE ____ _____ (Fill in amount)

d.

RESUBMISSION AFTER REJECTION
TTB ID. NO. ______
11. NET CONTENTS
750 MILLILITERS
12. ALCOHOL CONTENT
20
13. WINE APPELLATION IF ON LABEL
14. WINE VINTAGE DATE IF ON LABEL
15. PHONE NUMBER
(202) 213-3757
16. FAX NUMBER
18. SHOW ANY WORDING (a) APPEARING ON MATERIALS FIRMLY AFFIXED TO THE CONTAINER (e.g., caps, celoseals, corks, etc.) OTHER THAN THE LABLES AFFIXED BELOW, OR (b) BLOWN, BRANDED OR EMBOSSED ON THE CONTAINER (e.g., net contents etc.). THIS WORDING MUST BE NOTED HERE EVEN IF IT DUPLICATES PORTIONS OF THE LABELS AFFIXED BELOW. ALSO, PROVIDE TRANSLATIONS OF FOREIGN LANGUAGE TEXT APPEARING ON LABELS.
PART II - APPLICANT'S CERTIFICATION
Under the penalties of perjury, I declare; that all statements appearing on this application are true and correct to the best of my knowledge and belief; and, that the representations on the labels attached to this form, including supplemental documents, truly and correctly represent the content of the containers to which these labels will be applied. I also certify that I have read, understood and complied with the conditions and instructions which are attached to an original TTB F 5100.31, Certificate/Exemption of Label/Bottle Approval.
19. DATE OF APPLICATION
05/31/2005
20. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
21. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
DEBORAH RINGO
PART III - TTB CERTIFICATE
This certificate is issued subject to applicable laws, regulations and conditions as set forth in the instructions portion of this form.
22. DATE ISSUED
06/22/2005
23. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
Authorized Signature

FOR TTB USE ONLY
QUALIFICATIONS

STATUS
THE STATUS IS APPROVED.

CLASS/TYPE DESCRIPTION
OTHER SPECIALTIES & PROPRIETARIES

EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 3.48 inches W X 5.45 inches H


Label Image: Brand (front) or keg collar


Image Type:

Neck
Actual Dimensions: 3.88 inches W X .44 inches H


Label Image: Neck


Image Type:

Strip
Actual Dimensions: 2.5 inches W X .75 inches H


Label Image: Strip


Image Type:

Back
Actual Dimensions: 4.13 inches W X 4.13 inches H


Label Image: Back




TTB F 5100.31  (6/2006) PREVIOUS EDITIONS ARE OBSOLETE