Office use only Number ________________ Office use only Check Number ______________ Check Amount $_____________ Deposit Date_________________ Comptroller of Maryland MATT Regulatory Division P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7381 888-784-0145 YR ____________________ Stub No. _______________ Date ___________________ Issue __________________ Approval Date __________ Alcohol Awareness Permit Application Note • Read instructions carefully. Incomplete or incorrect applications will be returned. File a separate application for each type of permit desired. All permits expire October 31 Annually. • Office use only • • Check the type of permit you are applying for (select only one): G Alcohol Awareness Program Permit Annual fee $15.00 G Alcohol Awareness Instructor Permit Annual fee $ 5.00 Use typewriter or print in ink Section 1 - All Applicants Must Complete This Section G New Permit A. £ G Renewal (give old permit no.) Program Permit is to be issued in the name: Instructor Permit is to be issued in the name: Last B. Daytime telephone number: Area Code or 800 ( ) First FAX: ( M.I. ) E-mail address: C. Program’s address: (*) Street and Number County State Nine-Digit ZIP CODE (*) Street and Number D. City City County State Nine-Digit ZIP CODE Instructor’s address: (*) If the address is a P.O. Box or mailing address, please also provide physical location address E. Applicant is a: Corporation Limited Liability Co. G G } List Federal Identification No. Partnership Individual G G } List Social Security No.* – – – * The disclosure of applicant’s Social Security Number is mandatory and will be used for background investigations pursuant to Article 2B of the Annotated Code of Maryland. F. The applicant is presently the holder of the following Alcoholic Beverages Permits or Licenses issued by the State of Maryland, any other state, and/or the United States Government. (If additional space is needed, attach separate sheet.) If NONE, so state. Issuing Authority Type Expiration Date Number COM/ATT-753 Rev. 7-07 American LegalNet, Inc. www.FormsWorkflow.com Section 1 - Continued - All Applicants Must Complete This Section G. Has the applicant ever been convicted of a felony by any state or federal court? G Yes G No H. Does the applicant agree to conform to all the laws, rules and regulations of the State of Maryland relating to the business in which the applicant proposes to engage under this permit? G Yes G No I. Has the applicant ever been convicted of a violation of the laws of the United States, Maryland or any other state concerning alcoholic beverages, gaming, or gambling? (If yes, explain in detail on separate sheet - list offense, court, date, etc.) G Yes G No J. Article 2B of the Annotated Code of Maryland titled “Workers' Compensation Compliance” requires the evidence of such compliance prior to the issuance of any permit by this office. The applicant hereby affirms (complete one): Applicant G is not or G is an employer required to provide employee coverage by the Maryland Workers' Compensation Law and has secured such coverage. As evidence of such coverage, the following is submitted. 1.Name of Insurance ____________________________________________________________________ 2.Policy or Binder No. Section 2 - Alcohol Awareness Instructor Applicants Must Complete This Section A. Are you authorized by an Alcohol Awareness Program administrator to conduct training classes for an Alcohol Awareness Program? (If yes, attach copy of authorization letter or program certificate and program administrator must complete Section 6 of this application.) G Yes G No B. Attach letter listing your background and qualifications as an alcohol awareness program instructor to include a list of fluently spoken languages, if this program is to be instructed in a language other than english. Section 3 - Alcohol Awareness Program Applicants Must Complete This Section New or revised programs must provide a hard copy of the course outline (classroom or online) with the proposed effective date, instructor’s syllabus, testing component, sample student certificate, any other participant handouts. A. Does your program include a section on determining the lawful drinking age of a consumer? G Yes G No C. Does your program include instruction on how alcohol affects a person’s: 1. Body? 2. Behavior? G Yes G Yes G No G No D. Does your program include education on the dangers of drinking and driving? G Yes G No E. Does your program include effective ways to: 1. Minimize a customer’s chances of intoxication? 2. Cease service before customer becomes intoxicated? 3. Identify previously intoxicated customers and how to handle them? G Yes G Yes G Yes G No G No G No F. Do you have training for your alcohol awareness instructors? (If so, attach brief description. Also, attach a list of instructor names and corresponding approved Maryland permit numbers authorized to teach this program.) G Yes G No G. Has your program material been modified since the Division’s last approval? (If so, submit updated material with a proposed effective date.) G Yes G No American LegalNet, Inc. www.FormsWorkflow.com Section 4 - Alcohol Awareness Program Applicants Must list any alcohol awareness program offered in the State of Maryland Program Title:________________________________________________ E X A M P L E Version: On Premise Most current revision date: July 1, 2006 Allotted time for presentation:___ _ 3 hours____________ Format of Available Languages:_____English and Spanish________ Face to face proxy testing component required: G Yes G No Method of delivery? G Classroom G Internet: Website Address www.ex.com G Other (explain): Intended Audience: G Group G Individual Office Use Only G Approved G Disapproved Date of Decision: Permit Year: G Online A. Version: Most current revision date: Allotted time for presentation: Format of Available Languages: Office Use Only G Approved G Disapproved Date of Decision: Permit Year: Face to face proxy testing component required: G Yes G No Method of delivery? G Classroom G Internet: Website Address G Other (explain): Intended Audience: G Group G Individual G Online B. Version: Most current revision date: Allotted time for presentation: Format of Available Languages: Office Use Only G Approved G Disapproved Date of Decision: Permit Year: Face to face proxy testing component required: G Yes G No Method of delivery? G Classroom G Internet: Website Address G Other (explain): Intended Audience: G Group G Individual G Online C. Version: Most current revision date: Allotted time for presentation: Format of Available Languages: Office Use Only G Approved G Disapproved Date of Decision: Permit Year: Face to face proxy testing component required: G Yes G No G Internet: Website Address Method of delivery? G Classroom G Other (explain): Intended Audience: G Group G Individual G Online D. Version: Most current revision date: Allotted time for presentation: Format of Available Languages: Office Use Only G Approved G Disapproved Date of Decision: Permit Year: Face to face proxy testing component required: G Yes G No G Internet: Website Address Method of delivery? G Classroom G Other (explain): Intended Audience: G Group G Individual G Online American LegalNet, Inc. www.FormsWorkflow.com Section 5 - All Applicants Must Complete This Section Affidavit I do solemnly declare and affirm under the penalties of perjury that the contents of the foregoing document(s) are true and correct to the best of my knowledge, information and belief. Signature of Applicant Type or Print Name of Applicant Title Date Section 6 - Approved Program Administrator Must Complete This Section for Alcohol Awareness Instructor Applicants I authorize the alcohol awareness instructor applicant to conduct all(*) versions of the program named below and approved by the Comptroller. Yes No (*) If authorization is limited to specific versions, please specify which versions are approved: I understand that I am responsible for this instructor’s activities under this permit, and that if this instructor violates alcoholic beverages laws or regulations, or conducts a training course contrary to the one approved and on file with the MATT (Motor-fuel, Alcohol and Tobacco Tax) Regulatory Division, the alcohol awareness program permit may be subject to administrative action, including suspension or revocation. Signature (*) must be the same individual who signed the Alcohol Awareness Program Permit Application for the current permit year. Signature (*) Type or Print Administrator Name Title Date Name of Licensed Program Program Address Telephone Number Alcohol Awareness Program Permit Number If additional space is needed for any section, attach separate sheets. INCOMPLETE APPLICATIONS WILL BE RETURNED TO YOU UNPROCESSED. American LegalNet, Inc. www.FormsWorkflow.com