Permit# Stub# Date Issued Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax Louis L. Goldstein Treasury Building P. O. Box 2999 Annapolis, Maryland 21404-2999 1-888-784-0145 410-260-7314 Fax# 410-974-3201 OFFICE USE ONLY Check# _____________________ Check Amount$ Deposit______________________ Date Approved ___________________ Date _______________________ Application for Charity Wine Auction Permit Section 1 A. B. C. D. Name of Charitable Organization Mailing Address Telephone number and area code Premises in Maryland where event is to be held Yes 9 No 9 E. Is this a retail license premise? F. Date event is to be conducted G. Federal Identification Number H. Social Security number of organization (Official Making Application) Section 2 A. Has the applicant ever been convicted of a felony by any state or federal court? . . . . . . . . . . Yes 9 No 9 B. Does the applicant agree to conform to all the laws, rules and regulations of the state of Maryland relating to the business in which he proposes to engage under this permit? . . . . . . Yes 9 No 9 C. Does the applicant authorize the Comptroller of Maryland and his duly authorized personnel to search without warrant any vehicle, railroad cars, vessel, aircraft or premises used in the business to be conducted under this permit at any and all hours agreeable to the laws of the State of Maryland? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes 9 No 9 D. Has the applicant ever been convicted of a violation of the law of the United States, Maryland or any other state concerning alcoholic beverages, gaming or gambling? . . . . . . . Yes 9 No 9 (If yes, explain in detail on separate paper - list offense, court, date, etc.) E. Section 1-204 of the Tax General Article 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 (check one): 9 a. the applicant is not an employer required to provide coverage by the Maryland Workers Compensation Law; or 9 b. the applicant 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 company 2. Policy or binder number American LegalNet, Inc. www.FormsWorkflow.com Owner of Premises Statement Section 3 Physical description of premises applied for The premises is owned by Whose mailing address is (I) (We) certify that (I am) (We are) the owner(s) of the above described premises, and (I) (We) hereby consent to the use of the premises in the conduct of the businesses to be engaged in under the permit applied for and (I) (We) authorize the Comptroller of the State of Maryland and his duly authorized inspectors to inspect and search without warrant, the premises so described at any and all hours. WITNESS (My) (Our) hand(s) this day of 20 WITNESS WITNESS Owner's signature Owner's signature (L.S.) (L.S.) Section 4 A. B. Permit fee is $10.00 (remitted herewith) Prepayment of taxes: Within seven (7) days of the date of the auction (see Section 1F), applicant must remit an estimated prepayment of the wine tax on wine anticipated to be sold at auction on which the tax has not already been paid (reference Section 2-101 (9) (10), Article 2B, Annotated Code of Maryland). Note: Within 30 days from the date of the auction, our report Form 34-12 ATT is to be submitted to the Alcohol and Tobacco Tax office. Section 5 A. Extract from the Maryland Law: If any signed statement, report, affidavit or oath required under the provisions of the Alcohol Beverages Law shall contain any false statement, the offender shall be deemed guilty of perjury and upon conviction thereof, shall be subject to the penalties provided by law for that crime. By my signature below I understand that while I am making this application on behalf of the listed charitable organization, I will be considered a co-applicant and as such will be held personally accountable for filing report Form 34-12 ATT, paying the applicable excise tax and otherwise complying with the provisions of Article 2B. Signature of applicant (if a corporation, the president, vice president or secretary-treasurer) (L.S.) Corporate Officer B. State of County of This is to certify that on the before me the subscriber, a personally appeared himself (herself) to be Owner, partner or title of corporate officer Organizational Official day of in and for the State of of the 20 who represented , Trade or corporate name and made oath in due form of law that the statements contained herein are true and correct to the best of his (her) knowledge and belief. Whereof Witness My Hand and Seal (Seal) Officer administering oath American LegalNet, Inc. www.FormsWorkflow.com