MARYLAND FORM 369-1 APPLICATION FOR CLASS C SPECIAL LICENSE 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 Special Class C License for use on the following (check one): Boat / Name of Boat ________________________________________________________ Plane / Name of Airline ______________________________________________________ Train / Name of Railroad _____________________________________________________ Check one: Beer - $5.00 per day Beer and Wine - $10.00 per day Beer, Wine and Liquor - $15.00 per day I (we) submit and certify to the following information and statements as required by Article 2B. 1. APPLICANTS * 1 Name Residence Home Phone Date of Birth Place of Birth Social Security Number * * The disclosure of applicant's Social Security Number is mandatory and will be used for background investigations, including a criminal history records checks, pursuant to Section 10-201 of Article 2B, Annotated Code of Maryland. 2 3 OFFICE USE ONLY Check Number __________ Amount $ _____________ Deposit Date____________ License # ______________ Date Issued ____________ Approved ______________ Date _________________ 2. The club, society or association on behalf of which the license is desired: Name ________________________________________________________________________________________________ Address _______________________________________________________________________________________________ FederalIdentificationNumber isoperatedexclusivelyforeducational,social,fraternal,patriotic,politicalorathleticpurposesandnotforprofit. Yes Yes Yes No No No - 3. Are the applicants citizens of the United States, and over 21 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Have the applicants ever been convicted of a felony? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Have the applicants ever had a license for the sale of alcoholic beverages revoked? . . . . . . . . . . . . . . . . . . . . 6. Have the applicants ever been adjudged guilty of violating the law for the prevention of gambling in the state of Maryland and/or adjudged guilty of violating the laws governing the sale of alcoholic beverages in the state of Maryland or the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No COM/RAD-369-1 Revised 02/14 American LegalNet, Inc. www.FormsWorkFlow.com MARYLAND FORM 369-1 APPLICATION FOR CLASS C SPECIAL LICENSE Page 2 The applicants submit herewith a statement duly executed and acknowledged by the company on whose behalf the license is desired, assenting to the granting of the license applied for, authorizing the Comptroller, his duly authorized deputies, inspectors and clerks, to inspect and search, without warrant, the boat, plane or train to which such license applies, at any and all hours, provided no such inspection or search shall be made at such time or in such manner as to delay or interfere with movement of said boat, plane or train. The license for which this application is made is to be for the following days(s) ____________________________________________ _____________________ and the applicant tenders herewith the sum of ( per day) $ ____________ in payment for the license. Signature of applicant Signature of applicant Signature of applicant Statement of Company Required in Connection with Alcoholic Beverages Law of Maryland I hereby certify that I am the owner of (Name of boat, plane, or train) _________________________________________________ _________________ named in the application made by _____________________________________________________________ __________________________________________________________________________________________________________ to the Comptroller of Maryland under the Alcoholic Beverages Law of Maryland Class C Special License for the day(s) set forth herein; and that I assent to the granting of the license applied for, and that I hereby authorize the State Comptroller, his duly authorized deputies, inspectors and clerks to inspect and search, without warrant, any boat, plane or train to which such license applies, at any and all hours, provided no such inspection or search shall be made at such time or in such manner as to delay or interfere with the movement of such boat, plane or train. Affidavit Idosolemnlydeclareandaffirmunderthepenaltiesofperjurythatthecontentsoftheforegoingdocumentaretrueandcorrecttothe best of my knowledge, information, and belief. Signature of applicant Type or print name Title Date Third Party Checks Affidavit Idosolemnlydeclareandaffirmunderthepenaltiesofperjurythatthecontentsbelowaretrueandcorrecttothebestofmy knowledge, and that I am authorized and empowered to issue a check and make payment for the license/permit fee on behalf of the applicant. Name of Corporation; Partners of Partnership; or Individual (include Trade Name) Complete Mailing Address SignatureofOwner,PartnerorCorporateOfficer Title FederalIdentificationNumberand/orSocialSecurityNumber Date COM/RAD-369-1 Revised 02/14 American LegalNet, Inc. www.FormsWorkFlow.com