OMB No. 1513-0020

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

09286001000079

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

649

PART I - APPLICATION

2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)

DSP-CA-15081

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)

OLD WORLD SPIRITS, LLC.
121 INDUSTRAIL RD , #3 AND #4

BELMONT CA 94002

OLD WORLD SPIRITS, LLC (Used on label)

4. SERIAL NUMBER (Required)

091013

5. TYPE OF PRODUCT (Required)

	WINE
	DISTILLED SPIRITS
	MALT BEVERAGE

6. BRAND NAME (Required)

LA SORCIERE

8a. MAILING ADDRESS, IF DIFFERENT

7. FANCIFUL NAME (If any)

SUPERIEURE

9. EMAIL ADDRESS

10. FORMULA/SOP NO.
(If any)

04-09

11. LAB. NO. & DATE / PREIMPORT NO. & DATE (If any)

B-2009-00792-0 - 10/06/2009

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

50% ABV

14. WINE APPELLATION IF ON LABEL

15. WINE VINTAGE DATE IF ON LABEL

16. PHONE NUMBER

(650) 485-1009

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.
LA SORCIERE - FRENCH WORD FOR "THE SORCERESS" SUPERIEURE - FRENCH WORD INDICATING PREMIUM QUALITY OF PRODUCT AND INGREDIENTS BRAND NAME, PRODUCER NAME AND GRAPHICS MAY REPEAT ON CAP, CAPSULE, NECK OR STAMPED INTO TOP OF WAX CAP SEAL 750CL - STAMPED INTO BOTTOM OF BOTTLE

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 10/13/2009	21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT DAVORIN KUCHAN

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 10/13/2009	24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY
QUALIFICATIONS The finished product must be "Thujone-free" pursuant to 21 CFR 172.510 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 inches W X 4 inches H

Label Image: Brand (front) or keg collar

Image Type:

Back
Actual Dimensions: 3 inches W X 4 inches H

Label Image: Back

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