COMPTROLLER OF MARYLAND MATT Regulatory Division ALCOHOL AND TOBACCO TAX P.O. BOX 2999 ANNAPOLIS, MARYLAND 21404-2999 1-888-784-0145 (410) 260-7327 FAX (410) 974-3201 OFFICE USE ONLY Check Number ------------------------------ Check Amount ------------------------------- Deposit Date ______________________ OFFICE USE ONLY Approved Date -----------------------------------------Permit Number -------------------------------------Stub # ---------------------------------------Date Issued http://compnet.comp.state.md.us/ APPLICATION FOR FUEL-ALCOHOL PERMIT NOTE: READ INSTRUCTIONS ON REVERSE SIDE CAREFULLY-INCOMPLETE OR INCORRECT APPLICATION WILL BE RETURNED. SECTION 1 A) Permit is to be issued in the name of................................................................................................................................................................ B) Whose telephone number is ...................................... and/or (800) - ........................................ Fax Number ................................... C) Whose mailing address is ............................................................................................................................................................... (street & number) (city) (county) (state) (nine digit zip code) D) List Social Security Number* List Federal Employee Identification Number *The disclosure of applicant’s Social Security Number is mandatory and will be used for background investigations pursuant to Section 10201 of Article 2B of the Annotated Code of Maryland. E) The applicant is presently the holder of the following Alcoholic Beverages Permits of Licenses issued by the State of Maryland, any other State or the United States Government (if additional space is needed, attach separate paper). If NONE, so state. Type Expiration Date Number Issuing Authority F) Has the applicant ever been convicted of a felony by any State or Federal Court? .............................................G Yes G No G) 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 in under this permit? ....................................G Yes G No H) 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?......................G Yes G No 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? .................................................................G Yes G No (If yes, explain in detail on a separate paper - list offense, court, date, etc.) J) Section 9-104 of Article 2B of the Annotated Code of Maryland titled “Workmen’s Compensation Compliance” requires the evidence of such compliance prior to the issuance of any permit by this office. The applicant hereby affirms (complete one): ........................ (a) the applicant is not an employer required to provide coverage by the Maryland Workmen’s Compensation Law; or ........................ (b) the applicant is an employer required to provide coverage by the Maryland Workmen’s Compensation Law and has secured such coverage. As evidence of such coverage, the following is submitted: 1. 2. Name of Insurance Co.................................................................................................................. Policy or Binder No. .................................................................................................................. SECTION 2 A) If premises is in MARYLAND give EXACT site location (do not give P.O. address) .............................................................................................................................................................................................................. (street & number) (city) (state) (other site location) B) Physical description of premises applied for (see instructions) ............................................................................................................ C) The premises is owned by..................................................................................................................................................................... D) Whose mailing address is ..................................................................................................................................................................... E) (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 business 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. ..................................................................................... (Type or Print Name) (Title) ............................................................................................ (Owner’s Signature) ............................................................................................ (Date) SECTION 3 I certify under penalty of perjury that the aforementioned statements are true and correct to the best of my knowledge and belief. I further certify that alcohol produced under this permit will be used exclusively for fuel purposes and not for beverage purposes. I agree to file reports as may be required from time to time and understand that failure to do so ay result in the suspension or revocation of my permit. ......................................................................................... Signature of Applicant ............................................................................................. Date of Application COM/ATT-010-6 Rev. 7/07 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING FORM COM/ATT-010-6 APPLICATION FOR FUEL - ALCOHOL PERMIT SECTION 1 I) State in whose name the permit is to be issued. If applicant is a corporation, the corporate name should be listed and corporate officers should be listed on a separate sheet. If the applicant is a partnership, the permit must be issued in the names of all partners. If an LLC, indicate the managing members’ names on a separate sheet. J) State the applicant’s telephone number including area code and fax number, if applicable. K) Indicate the address where mail will reach the applicant showing street and number or Post Office Box, City, County, State and nine digit Zip Code. L) List the applicant’s Social Security Number and Federal Employer Identification Number, if applicable. M) State whether the applicant is the holder of any type of alcoholic beverage license or permit under the authority of the State of Maryland, the United States Government, or any other State or subdivision thereof. If the applicant is the holder of such a permit or license, list all such permits or licensing in the space provided. If the applicant does not hold any such permits, list “none”. Note: See Special Instructions below pertaining to your federal permit for fuel-alcohol use. N) Indicate whether or not the applicant has ever been convicted of a felony in any State or federal court. O) The applicant’s signature at the bottom of the application indicates his willingness to conform to all the laws of the State of Maryland and any rules or regulations which have been or may hereafter be promulgated concerning alcoholic beverages generally and this class of permit particularly. P) The applicant’s signature at the bottom of this application signifies his consent to the search without a warrant of any premises which are used in the conduct of the business engaged in under this permit at any and all hours by the Comptroller of his duly authorized personnel. Note: Section 2 of this application must also be completed. Q) If the applicant has ever been convicted in any State or federal court for violation of the laws pertaining to alcoholic beverages, gaming or gambling indicate the name under which the applicant was convicted, the offense, the court where the applicant was convicted and the date of conviction on a separate piece of paper. R) The applicant is to complete either (a) or (b) indicating his compliance with the Maryland Workmen’s Compensation Law. SECTION 2 I) Indicate the exact site location of the permit premises showing street or number, if any, or if none, indicate the distance and direction of the nearest prominent landmark. Also, show the City and County where the premises is located. II) Indicate the physical description of the premises. III) Indicate the owner of the permit premises and his mailing address. If the applicant is the owner, so state. IV) List the mailing address of the owner. V) The owner of the permit premises (whether he is the applicant or another person), must execute a Certificate of Consent for a search of the premises. Date and sign it in the presence of a witness. SECTION 3 In this section, you are to sign and date the application. SPECIAL NOTES FOR FUEL-ALCOHOL PERMIT APPLICANTS F) Attached to this application must be a copy of your federal permit to operate a fuel-alcohol operation. If you have not obtained such a permit, then submit a copy of your application for same and submit copy of permit when received. This office will not issue a fuel-alcohol permit before evidence is presented that you have obtained a federal permit. G) There is no fee for this type of permit. The duration of the permit is perpetual unless the permit is suspended or revoked by the Comptroller. H) As a permittee, you will be required to comply with certain requirements of this office. Please refer to ADDITIONAL INFORMATION below for complete details. I) Any questions pertaining to this permit application or the activities thereunder should be directed to the Alcohol and Tobacco Tax office at (410) 260-7327. ADDITIONAL INFORMATION The holder (or potential holder) of a Fuel-Alcohol Permit shall be aware of and comply with the following: A) Before a permit will be issued by the Alcohol and Tobacco Tax office, evidence must be made a part of the Application Form 10-6 ATT that the applicant holds a federal Fuel-Alcohol Permit. This shall be in the form of a copy of the actual permit or authorization letter. B) Each application is subject to an investigation by representatives of the Field Enforcement Division prior to issuance. In any event, prior to initiating operations under this permit, a 48-hour notice shall be given to the Field Enforcement Division (410-260-7388), so that they may arrange to have an authorized representative on the site at that time. C) A yearly report of your activity is required. Report Form 22 ATT covering activity between November 1 through October 31 of each year (or that portion of the year you held a permit) must be filed by November 15 annually. This form must be filed even if you had no activity under your permit during your report period. Failure to file this report on a timely basis will subject your permit to suspension or revocation. D) Fuel-Alcohol Permits do not expire. They will continue in effect until suspended, revoked or you are otherwise notified by the Comptroller. Permits no longer needed shall be immediately returned to the Alcohol and Tobacco Tax office for voluntary cancellation. American LegalNet, Inc. www.FormsWorkflow.com