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30165 1 and acknowledges and understands that any person who makes this certification and
ADDRESS
Applicants for a Distributor s License under section 30140 of the Revenue and Taxation Code must
asserts the truth of any material matter that he or she knows to be false is guilty of a misdemeanor
BOARD OF EQUALIZATION
BOE 443 (2 04) STATE OF CALIFORNIA
by an authorized agent For a partnership attach authorization signed by all general partners; for a
certification
certify they will fully comply with section 30165 1 of the Revenue and Taxation Code (copy enclosed)
completed power of attorney must be attached to this certification
COMPLIANCE CERTIFICATION
corporation attach corporate resolution; and for a LLC attach articles of organization which authorize
DISTRIBUTOR NAME
NAME OF PERSON AUTHORIZED TO SIGN (typed or printed)
Note: This form must be signed by an owner partner corporate officer LLC member or manager or
punishable by imprisonment of up to one year in county jail or a fine of not more than $1 000 or both
Revenue and Taxation Code Section 30165 1
SIGNATURE OF PERSON AUTHORIZED TO SIGN DATE
The distributor identified below certifies that it will comply fully with Revenue & Taxation Code section
the fine and imprisonment
the individual who signs below to make this certification If signed by an authorized agent a properly
TITLE
Your application will not be processed or approved if it is incomplete or submitted without the proper
