OMB No. 1513-0020  (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
09154001000018
1. REP. ID. NO. (If any)
CT
956
OR
83
PART I - APPLICATION
2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
GA-I-15083
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)

PREMIUM BEVERAGE IMPORTS, LTD.
10 GLENLAKE PKWY , SUITE 130

ATLANTA GA 30328
4. SERIAL NUMBER (Required)
091016
5. TYPE OF PRODUCT (Required)
WINE
DISTILLED SPIRITS
MALT BEVERAGE

6. BRAND NAME (Required)
IKI
8a. MAILING ADDRESS, IF DIFFERENT
7. FANCIFUL NAME (If any)
GREEN TEA BEER
9. EMAIL ADDRESS
 
10. FORMULA/SOP NO.
(If any)
11. LAB. NO. & DATE / PREIMPORT NO. & DATE (If any)
09141003000023 - 05/26/2009
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
11.15 Ounces
13. ALCOHOL CONTENT
4.5%
14. WINE APPELLATION IF ON LABEL
15. WINE VINTAGE DATE IF ON LABEL
16. PHONE NUMBER
(646) 964-6715
17. FAX NUMBER
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.
THE BRAND LABEL IS NOW DIMENSIONALIZED PRECISELY AS IT WILL APPEAR ON THE LABEL OF THE 11.15 OUNCE BOTTLE. 2.30" H X 3.50" W
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
06/03/2009
21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
CHARLES VAUGHN
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
06/10/2009
24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
Authorized Signature

FOR TTB USE ONLY
QUALIFICATIONS
When new labels are printed, all the mandatory information excluding the alcohol content must appear in printing not smaller than two (2) millimeters. This includes lower case lettering. See 27 CFR 7.28 (b) (1). (List information to be corrected) (NET CONTENTS, STATEMENT OF COMPOSITION)

STATUS
THE STATUS IS SURRENDERED.

CLASS/TYPE DESCRIPTION
MALT BEVERAGES SPECIALITIES
EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 2.30 inches W X 3.50 inches H


Label Image: Brand (front) or keg collar


Image Type:

Neck
Actual Dimensions: .60 inches W X .60 inches H


Label Image: Neck


Image Type:

Back
Actual Dimensions: 2.40 inches W X 3.50 inches H


Label Image: Back



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