Permit # ______________ Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax Louis L. Goldstein Treasury Building P.O. Box 2999 Annapolis, Maryland 21404-2999 Stub # ________________ Date issued ____________ Approved ____________ Date _________________ For Office Use Only Check Number ________________ Check Amount $ _______________ Deposit Date ___________________ Application for a Special Event Permit Check one: Winery Brewery Date To the Comptroller of Maryland Application is made by the undersigned under the provisions of Article 2B of the Annotated Code of Maryland, as amended, title “Alcoholic Beverages” for the permit indicated above. This application shall be filed with the Office of the Comptroller not less than 15 days prior to any event. 1. License name and/or trade name: 2. Mailing address: Business Phone No.: License Number M Federal Identification Number - - 3. Location (complete address) and political subdivision (specify county) where winery permit is desired: 4. Is the event being held on the premises of the brewery? (For Class 5 breweries only)........................... Yes No 5. Do the applicants agree to conform to all laws, rules, and regulations of the State of Maryland relating to the business in which they propose to engage under this permit? .......................................... Yes No 6. The permit for which this application is made is to be for the following day(s) The applicant tenders herewith the sum of $25.00 in payment. COM/ATT-012 Rev. 4/08 (over) American LegalNet, Inc. www.FormsWorkflow.com 7. Must be signed by a winery or brewery licensee. Affidavit I/we do solemnly declare and affirm under 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 Winery/Brewery Licensee Type or Print Name 8. This section must be completed by the owner of the premises where the event will take place. Statement of owner of premises required in connection with alcoholic beverages law of Maryland: I/we hereby certify that I am/we are the owner(s) of the property known as named as the foregoing application made to the Comptroller of Maryland under the Alcoholic Beverages Law of Maryland; that I/we assent to the granting of the permit applied for, and that I/we hereby authorize the Comptroller of Maryland, his duly authorized deputies, inspectors and clerks, the Board of License Commissioners of the jurisdiction in which the place of business is located, its duly authorized agents and employees, and any peace officer of such jurisdiction to inspect and search, without warrant, the premises upon which the business is to be conducted, and any and all parts of the building in which said business is to be conducted, at any and all hours. Affidavit I do solemnly declare and affirm under penalties of perjury that the contents of the foregoing document are true and correct to the best of my knowledge, information and belief. Signature Type or print name Title Date American LegalNet, Inc. www.FormsWorkflow.com