Office use only Number ________________ YR ____________________ Stub No. _______________ Date ___________________ Issue __________________ Comptroller of Maryland MATT Regulatory Division P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7381 888-784-0145 Office use only Check Number ______________ Check Amount $_____________ Deposit Date_________________ 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 G Alcohol Awareness Instructor Permit Annual fee Annual fee $15.00 $ 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 First M.I. B. Daytime telephone number: Area Code or 800 E-mail address: ( ) FAX: ( ) C. Program's address: (*) Street and Number City County State Nine-Digit ZIP CODE D. Instructor's address: (*) Street and Number City County State Nine-Digit ZIP CODE (*) 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. Partnership Individual G G G G } } List Federal Identification No. ­ 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? 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? 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 G Yes G No 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 C. Does your program include instruction on how alcohol affects a person's: 1. Body? 2. Behavior? D. Does your program include education on the dangers of drinking and driving? 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? 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. Has your program material been modified since the Division's last approval? (If so, submit updated material with a proposed effective date.) G No G No G No G No G No G No G No G No G Yes G Yes G Yes G Yes G Yes G Yes G Yes 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 G Online Office Use Only G Approved G Disapproved Date of Decision: Permit Year: A. Version: Most current revision date: Allotted time for presentation: Format of Available Languages: 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 Office Use Only G Approved G Disapproved Date of Decision: Permit Year: B. Version: Most current revision date: Allotted time for presentation: Format of Available Languages: 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 Office Use Only G Approved G Disapproved Date