Office Use Only Number Stub Year Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7314 or 888-784-0145 Office Use Only Check No. Check Amt. Deposit Date Approved Application for National Family Beer and/or Wine Exhibition Permit Section 1 A. Name of Non-Profit National Family Beer and/or Wine Association: B. Mailing Address: C. Telephone Number with Area Code: -- Fax Number: Date D. Federal Identification Number: E. Premises in Maryland where event is to be held: F. Is this a retail alcoholic beverage license premise: G. Date(s) event is to be conducted: Yes G No G Section 2 A. Has the applicant ever been convicted of a felony by any state or Federal Court? .......................................... Yes G No G No G B. Does the applicant agree to confirm to all the laws, rules, and regulations of the state of Maryland relating to the business which is proposed to be engaged in under this permit? ....................................................................... Yes G 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 G D. 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? (If yes, explain in detail on separate paper - list offense, court, date, etc.) ......................................................... Yes G No G No G E. 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 permit by this office. The applicant hereby affirms (complete one): a. Applicant is not an employer required to provide coverage by the Maryland Workers' Compensation Law; or b. 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: COM/ATT-10-7 Rev. 7/07 American LegalNet, Inc. www.FormsWorkflow.com Section 3 (To be completed only if you answered "No" to question F in Section 1) Owner of premises statement: 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 business to be engaged in under the permit applied for and (I/we) authorize the Comptroller of Maryland and his duly authorized personnel to inspect and search without warrant the premises so described at any and all hours. WITNESS (my/ours) hand(s) and seal(s) this Month Day Year WITNESS (Owner's Signature) (L.S.) WITNESS (Owner's Signature) Section 4 (Fees) A. B. Permit Fee: ......................................................... $ 50.00 Beer ............................... $ Wine .............................. $ Total Tax ........... $ Prepayment of Taxes*: Remitted herewith ................................................................................................. $ * Determined by estimating the number of gallons of commercially produced beer or wine to be received from non-Maryland licensed manufacturers or suppliers and multiplying by the wine tax rate of 40¢ per gallon or the beer tax rate of 9¢ per gallon. NOTE: Within 30 days of the close of the event, Form COM/ATT-34-11 is to be completed and submitted to the Alcohol and Tobacco Tax office. Section 5 - All applicants must complete this section. Affidavit I solemnly declare and affirm under penalties of perjury that the contents of the foregoing documents are true and correct to the best of my knowledge, information, and belief. Signature of Applicant (If a corporation - the president, vice-president, or secretary/treasurer) Type or Print Name of Applicant Title Date If additional space is needed for any section, attach separate sheets. American LegalNet, Inc. www.FormsWorkflow.com