OMB No. 1513-0020 (01/31/2009)
FOR TTB USE ONLY
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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)
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TTB ID
10050001000090
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1. REP. ID. NO. (If any)
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CT
906
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OR
04
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PART I - APPLICATION
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2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
BR-IL-FUL-15000
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3. SOURCE OF PRODUCT (Required)
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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)
GOOSE ISLAND BEER COMPANY, FULTON STREET BREWERY, LLC
1800 W FULTON ST
CHICAGO
IL
60612
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4. SERIAL NUMBER (Required)
100003
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5. TYPE OF PRODUCT (Required)
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6. BRAND NAME (Required)
GOOSE ISLAND BEER COMPANY
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8a. MAILING ADDRESS, IF DIFFERENT
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7. FANCIFUL NAME (If any)
BOURBON COUNTY COFFEE STOUT
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9. EMAIL ADDRESS
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10. FORMULA/SOP NO. (If any)
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11. LAB. NO. & DATE / PREIMPORT NO. & DATE (If any)
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18. TYPE OF APPLICATION (Check applicable box(es))
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12. NET CONTENTS
1 PT. 6 FL. OZ. (22 FL. OZ.)
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13. ALCOHOL CONTENT
13%
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14. WINE APPELLATION IF ON LABEL
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15. WINE VINTAGE DATE IF ON LABEL
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16. PHONE NUMBER
(312) 262-4641
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17. FAX NUMBER
(312) 733-1692
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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.
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PART II - APPLICANT'S CERTIFICATION
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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.
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20. DATE OF APPLICATION
02/19/2010
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21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
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22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
EILIS
BRICK
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PART III - TTB CERTIFICATE
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This certificate is issued subject to applicable laws, regulations and conditions as set forth in the instructions portion of this form.
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23. DATE ISSUED
03/01/2010
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24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
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FOR TTB USE ONLY
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QUALIFICATIONS
STATUS
THE STATUS IS
APPROVED.
CLASS/TYPE DESCRIPTION
MALT BEVERAGES SPECIALITIES - FLAVORED
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EXPIRATION DATE (If any)
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AFFIX COMPLETE SET OF LABELS BELOW
Image Type:
Brand (front) or keg collar
Actual Dimensions: 6.5 inches W X 4.6 inches H
Note: The image below has been reduced to fit the page. See actual dimensions above.
TTB F 5100.31 (6/2006) PREVIOUS EDITIONS ARE OBSOLETE