Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax Louis L. Goldstein Treasury Building P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7327 888-784-0145 For Office Use Only Number Stub Year For Office Use Only Check # Check Amt. $ Deposit Date Approved Date Fax # 410-974-3201 Application for Manufacturer’s and Wholesaler’s Licenses For the use of: (Check one) An individual G Partnership G Check Class(es) of License(s) desired: Corporation G Limited Liability Co. G Date , 2 Manufacturer’s Licenses G Class 1 Distillery Annual Fee G Class 2 Rectifying Annual Fee G Class 3 Winery Annual Fee Wholesaler’s Licenses G Class 1 Beer, Wine and Liquor Annual Fee $2,000.00 $600.00* G Class 2 Wine and Liquor Annual Fee $1,750.00 $750.00* G Class 3 Beer and Wine Annual Fee $1,500.00 $2,000.00 G Class 4 Limited Winery Annual Fee $200.00 G Class 4 Beer Annual Fee $1,250.00 G Class 5 Brewery Annual Fee $1,500.00* G Class 5 Wine Annual Fee $1,250.00 G Class 6 Pub-Brewery Annual Fee $500.00 G Class 6 Limited Wine Annual Fee $50.00 G Class 7 Micro-Brewery Annual Fee $500.00 * If you desire to sell to retailers, you will also need a Wholesaler’s License of the proper class. • • • $200.00 non-refundable application fee must be submitted with any initial license application. Upon approval of your initial application, you will be notified of the appropriate prorated license fee to submit. Wholesale licensees of any class using this form to apply for wholesale licenses for additional locations need not submit the $200.00 non-refundable application fee. Application is made by the undersigned under the provisions of Article 2B, as amended, title "Alcoholic Beverages", for the Class(es) of License(s) as checked above, and the applicant(s) submit and certify to the following information required by law. • 1. Applicants * (1) (2) (3) Name Residence Home Phone Date of Birth Place of Birth Social Security Number ** Qualifying Maryland Resident? *** G Yes G No MD Resident since G Yes MD Resident since G No G Yes G No MD Resident since * In the case of a corporation, the law requires three officers to apply as license applicants, unless less than three exist. (In the latter case, submit supporting documentation.) ** The disclosure of applicant's Social Security Number is mandatory and will be used for background investigations pursuant to Section 10-201 of Article 2B of the Annotated Code of Maryland. *** At least one applicant must be a voter and taxpayer in Maryland presently and for the two immediately preceding years. In case of partnership, all individuals must meet this requirement. 2. Company name and/or trade name (over) American LegalNet, Inc. www.FormsWorkflow.com 3. a. Location of desired licensed premises (complete address, include nine digit ZIP code) b. Additional location (if applicable) 4. Description of premises to be covered under license applied for (lot, type, size and construction of building) 5. Business phone number(s) ( ) Fax Number ( ) E-mail address: a. Date business began b. Type of accounting period (calendar yr, fiscal yr, etc.) Month FY begins c. If corporation or limited liability company, date chartered State d. Federal Employer Identification Number 6. Name and address of the owner of premises 7. The applicants are presently the holders of the following alcoholic beverages licenses or permits issued by the state of Maryland, any other state or jurisdiction, or the United States government (if more space is needed, attach additional sheet). Issuing Authority Type Expiration Date 8. The applicants have previously held the following alcoholic beverage licenses or permits: 9. Number The applicants have applications pending for the following alcoholic beverage licenses or permits: 10. Please answer each of the following questions applicable to all individual applicants: (attach explanation if “Yes” to (*) questions): *a. Has any applicant ever been convicted of a felony by any state or federal court? . . . . . . . . . . . . . . . . G Yes G No *b. Has any 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 *c. Has any applicant ever been denied or had revoked an alcoholic beverage license or permit? . . . . . G Yes G No *d. Has any applicant ever been convicted of a controlled dangerous substance offense which was committed on or after January 1, 1991? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes G No *e. Are any of the applicants pecuniarily interested in any other place of business with a retail alcoholic beverage license issued or applied for? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes G No *f. Are any of the applicants’ immediate families pecuniarily interested in a retail license? . . . . . . . . . . . G Yes G No g. Do the applicants agree to conform to all the laws, rules and regulations of the state of Maryland relating to the business in which they propose to engage under this license? . . . . . . . . . . . . . . . . . . . G Yes G No h. Do the applicants agree that they will not furnish anything of value to a retail licensee except advertising and related items provided by Section 12-104 of Article 2B of the Annotated Code of Maryland and regulations and bulletins issued by the Comptroller? . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes G No i. Do the applicants authorize the Comptroller and his duly authorized personnel to search without warrant any premise or vehicle used in the business to be conducted under this license at any and all hours agreeable to the state of Maryland? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes G No j. Do the applicants produce not more than 27,500 gallons of their own wine annually? (To be answered by Class 6 Limited Winery wholesale applicants only) . . . . . . . . . . . . . . . . . . . . . . . G Yes G No American LegalNet, Inc. www.FormsWorkflow.com 11. Section 9-104 of Article 2B of the Annotated Code of Maryland titled “Workers’ Compensation Compliance” requires the evidence of such compliance prior to the issuance of any license by this office. The applicant hereby affirms (complete one): G a. the applicant is not an employer required to provide coverage by the Maryland Workers’ Compensation Law; or, G b. the applicant is an employer required to provide employee coverage by the Maryland Workers’ Compensation Law and has secured such coverage as evidenced by the certificate of compliance attached herewith; or G c. 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 Co. 2. Policy or Binder No. 12. All applicants must complete this section 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. Print name(s) and address(es) of officer(s): (Note: All officers must be listed - attach separate sheet if necessary.) Name Title Residence Name Title Residence Name Title Residence Name Title Residence Signature of president or vice-president Note: If president or vice-president is one of the applicants, he/she must sign both as president/vice-president and as applicant. Signature of applicant Signature of applicant Signature of applicant American LegalNet, Inc. www.FormsWorkflow.com This Section Must be Completed by the Owner of the Premises 13. 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 property known as named in the afore going application made to the State Comptroller under the Alcoholic Beverages Law of Maryland; that (I / we) assent to the granting of the license applied for, and that (I/we) hereby authorize the State Comptroller, 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 building in which said business is to be conducted, at any and all hours. 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 Type or print name Title Date COM/ATT-007 Revised 7/07 American LegalNet, Inc. www.FormsWorkflow.com