OMB No. 1513-0020 (07/31/2015)
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
12261001000159
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1. REP. ID. NO. (If any)
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CT
149
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OR
41
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PART I - APPLICATION
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2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
DSP-SC-15001
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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)
TERRESSENTIA CORPORATION
9770 PATRIOT BLVD , SUITE 300
NORTH CHARLESTON
SC
29456
CHICKEN COCK DISTILLERS (Used on label)
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4. SERIAL NUMBER (Required)
120147
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5. TYPE OF PRODUCT (Required)
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6. BRAND NAME (Required)
CHICKEN COCK
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8a. MAILING ADDRESS, IF DIFFERENT
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7. FANCIFUL NAME (If any)
ROOT BEER
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9. EMAIL ADDRESS
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10. GRAPE VARIETAL(S) (Wine Only)
N/A
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11. FORMULA
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18. TYPE OF APPLICATION (Check applicable box(es))
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12. NET CONTENTS
50 MILLILITERS
200 MILLILITERS
750 MILLILITERS
1 LITER
1.75 LITERS
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13. ALCOHOL CONTENT
43
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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
(843) 376-2930
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17. FAX NUMBER
(843) 225-3107
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19. SHOW ANY INFORMATION THAT IS BLOWN, BRANDED, OR EMBOSSED ON THE CONTAINER (e.g., net contents) ONLY IF IT DOES NOT
APPEAR ON THE LABELS AFFIXED BELOW. ALSO, SHOW 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
09/17/2012
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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
CARY
ALEXANDRE
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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
09/21/2012
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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
TTB has not reviewed this label for type size, characters per inch or contrasting background. The responsible industry member must continue to ensure that the mandatory information on the actual labels is displayed in the correct type size, number of characters per inch, and on a contrasting background in accordance with the TTB labeling regulations, 27 CFR parts 4, 5, 7, and 16, as applicable.
STATUS
THE STATUS IS
APPROVED.
CLASS/TYPE DESCRIPTION
OTHER WHISKY (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: 6.97 inches W X 10.75 inches H
Note: The image below has been reduced to fit the page. See actual dimensions above.
Image Type:
Back
Actual Dimensions: 3.44 inches W X 11.10 inches H
TTB F 5100.31 (07/2012) PREVIOUS EDITIONS ARE OBSOLETE