Office Use Only Number Stub Year Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax Louis L. Goldstein Treasury Building P.O. Box 2999 Annapolis, MD 21404-2999 410-260-7327 888-784-0145 Fax# 410-974-3201 Office Use Only Check No. Check Amount $ Deposit Date Approved by Date Application for a Private Bulk Sale Permit Application is made by the undersigned under the provisions of Article 2B of the Annotated Code of Maryland, as amended, title "Alcoholic Beverages", for a Private Bulk Sale Permit and the applicant submits and certifies to the following information. Fee for Private Bulk Sale Permit - $25.00 (Make check payable to "Comptroller of Maryland") Section 1 - All applicants must complete this section. Type or print clearly. A. Permit is to be issued in the name of Applicant's Full Name B. Whose telephone number is ( C. Whose address is ) or Toll Free Street and Number City Fax ( State ) 9-Digit Zip Code D. Applicant's birth date MM/DD/YY E. Applicant's Social Security No. - - Section 2 - Applicant certifies to the following: A. All alcoholic beverages to be sold have been legally acquired and transported into Maryland, in accordance with the alcoholic beverage laws of Maryland. B. All alcoholic beverages intended for sale under a Private Bulk Sale Permit are owned by the applicant. C. Attached herewith is a complete inventory of alcoholic beverages to be sold under the Private Bulk Sale Permit. (Indicate on separate sheet the brand name, bottle size and number of bottles.) D. Applicant understands that a maximum of two Private Bulk Sale Permits may be obtained in a calendar year. (Over) COM/ATT-020-3A Rev. 7/07 9 Yes 9 Yes 9 Yes 9 Yes 9 No 9 No 9 No 9 No American LegalNet, Inc. www.FormsWorkflow.com Section 3 Identify who will be the seller of the alcoholic beverages identified in the inventory attached. (Check one) 9 9 Sale will be made by the individual permit applicant to the buyer. Sale will be made by an unlicensed agent or auction company acting on behalf of the permit applicant. Provide name and address of entity: Entity Name Street Address City State 9-Digit Zip Code Section 4 Indicate the intended buyer of the alcoholic beverages identified in the inventory attached. If unknown due to auction, check here. 9 9 A Maryland resident age 21 years of age or older. (Provide name and address.) MD Name Address City 9-Digit Zip Code 9 A Maryland retail account. (Indicate name, address and type/class of alcoholic beverage license.) MD Entity Name Entity Address City 9-Digit Zip Code Type of License (Beer/Wine/Liquor) License Number 9 Out of state entity authorized to receive alcoholic beverages. (Attach letter from State Alcoholic Beverage Board authorizing importation. Indicate entity name and address.) Entity Name Entity Address City State 9-Digit Zip Code Section 5 Affidavit I do solemnly declare and affirm under the penalties of perjury that the contents of the foregoing document are true and correct to the best of my knowledge, information and belief. Signature of Individual Date Type or Print Full Name If additional space is needed for any section, attach separate sheets. American LegalNet, Inc. www.FormsWorkflow.com