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 09107001000117
1. REP. ID. NO. (If any) 1049R CT 699 OR 51

PART I - APPLICATION
2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required) VA-I-627 3. SOURCE OF PRODUCT (Required) Domestic Imported	8. 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) J. CAMBIER IMPORTS, INC. 10001 HIGH HILL PL GREAT FALLS VA 22066
4. SERIAL NUMBER (Required) 090045 5. TYPE OF PRODUCT (Required) WINE DISTILLED SPIRITS MALT BEVERAGE
6. BRAND NAME (Required) DISTILLERIE GIRARD	8a. MAILING ADDRESS, IF DIFFERENT
7. FANCIFUL NAME (If any) FLEURS DU MAL

9. EMAIL ADDRESS	10. FORMULA/SOP NO. (If any) 1049R	11. LAB. NO. & DATE / PREIMPORT NO. & DATE (If any) 09026002000063 - 04/08/2009	18. 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. ______
12. NET CONTENTS 750 MILLILITERS	13. ALCOHOL CONTENT 55%	14. WINE APPELLATION IF ON LABEL
15. WINE VINTAGE DATE IF ON LABEL	16. PHONE NUMBER (703) 772-4448	17. FAX NUMBER (703) 759-6075
19. 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. PRODUCED AND BOTTLED BY DISTILLERIE GIRARD. FLEURS DU MAL: TITLE OF A BOOK BY BAUDELAIRE.

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.
20. DATE OF APPLICATION 04/17/2009	21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT JOCELYN CAMBIER

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.
23. DATE ISSUED 05/12/2009	24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY
QUALIFICATIONS STATUS THE STATUS IS APPROVED. CLASS/TYPE DESCRIPTION OTHER SPECIALTIES & PROPRIETARIES	EXPIRATION DATE (If any)

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AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 03.51 inches W X 05.12 inches H

Image Type:

Neck
Actual Dimensions: 4.50 inches W X 02.22 inches H

Image Type:

Back
Actual Dimensions: 02.00 inches W X 02.60 inches H

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