Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax Louis L. Goldstein Treasury Building P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7314/1-888-784-0145 Office Use Only Number Permit Year Stub Number Approved Date Office Use Only Check Number Check Amount $ Deposit Date Direct Wine Seller's Permit Application Section 1 - Applicant Information G New Permit G Renewal (Give Permit No.) A. Permit is to be issued in the name of: Applicant's Full Name and Trade Name, if applicable B. Whose telephone number is: Phone Toll Free Fax C. Whose address is: Street and Number City State Zip Code D. Provide physical location address if the mailing address is a P.O. Box: E. Applicant is a: Corporation Limited Liability Co. Partnership Individual G } List Federal Identification No. G G } List Social Security No. G – – – F. The applicant is presently the holder of the following alcoholic beverage permits or licenses issued by their home state, another state, the United States Government, or the State of Maryland: (Attach separate sheet if needed.) Issuing Authority Type Expiration Date Number G. 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. The applicant hereby affirms (complete one): G a. Applicant is not an employer required to provide coverage by the Maryland Workers' Compensation Law; or G b. 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, list the name of insurance company and policy or binder number: Name of Insurance Company Policy or Binder Number Rev. 7/07 COM/ATT-10-10 1 American LegalNet, Inc. www.FormsWorkflow.com Section 2 - Permit Information A. Does the applicant agree to conform to all the laws, rules, and regulations of the state of Maryland relating to the business proposed under this permit? ................................................ G Yes G No B. Does the applicant authorize the Comptroller of Maryland and the Comptroller's duly authorized personnel to search without warrant any vehicle, railroad car, 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 C. Are you the brand owner, United States importer, or designated Maryland agent of the brand owner or United States Importer for all wine to be sold under the direct wine seller's permit? (If importer or agent, attach certification from brand owner.) ................................... G Yes G No D. Do you presently hold, or have you held, a license or permit issued by this state within the past two years? .................................................................................................................................. G Yes G No E. Is your company owned, as a whole or in part, by another person or entity that holds an alcoholic beverages license or permit issued by this state or a political subdivision of this state? (If yes, attached separate explanation.) ............................................................................... G Yes G No F. Do you agree to file an annual tax return in accordance with § 5-201(d) of the Tax-General Article of the Annotated Code of Maryland and remit any applicable fee or tax when due? .... G Yes G No G. Do you agree to comply with any and all applicable regulations adopted by the Office of the Comptroller? .............................................................................................................................. G Yes G No H. Is the brand(s) of wine to be sold under this permit currently being distributed in this state by a wholesaler licensed in this state? ............................................................................................. G Yes G No I. Has the brand(s) of wine being sold under this permit been distributed within two years before making application for this permit? ............................................................................................ G Yes G No J. Do you agree to use only a public carrier licensed by the State of Maryland to transport product sold under this permit to the designated Maryland wholesaler? .................................................... G Yes G No K. Who is the Maryland wholesaler designated for receiving your product? Name and Trade Name: Maryland License No.: Address: City: State: 2 Zip: American LegalNet, Inc. www.FormsWorkflow.com Section 3 - Affidavit of Designated Wholesaler (To be completed by licensed Maryland wholesaler prior to application submission) I agree to be the designated Maryland wholesaler for this permit applicant. I agree to comply with applicable provisions of Title 7.5 of Article 2B of the Annotated Code of Maryland, Administrative Release No. AB-21, and any rules or regulations promulgated pertaining to this activity. Wholesaler License Name Signature of Owner, Partner, or Corporate Officer Type or Print Name of Owner, Partner, or Corporate Officer Title Date Section 4 - Affidavit of Wine Seller's Permit Applicant I do solemnly declare and affirm, under penalty of perjury, that the contents of the foregoing document are true and correct to the best of my knowledge, information, and belief. Signature of Owner, Partner, or Corporate Officer Type or Print Name of Owner, Partner, or Corporate Officer Title Date 3 American LegalNet, Inc. www.FormsWorkflow.com Section 5 - Direct Wine Seller's Permit - General Information 1. The holder of a direct wine seller's permit may only sell wine to a personal consumer who is at least 21 years of age, is a resident of Maryland, and who purchases wine for personal consumption only and not for resale or other commercial purposes. 2. The sales transaction is between the holder of the direct seller's permit and the consumer. The wholesaler designated by the permit holder and the retailer designated by the consumer only act as facilitators for delivery of the product and must be compensated by the consumer pursuant to Section 7.5-108 of Article 2B. 3. A direct wine seller's permit applicant must designate a licensed Maryland wholesaler prior to making application. Any wholesaler holding a wine wholesale license may be designated; however, only one wholesaler may be designated by a permit holder for facilitating shipments statewide. 4. The holder of a direct wine seller's permit, who holds an alcoholic beverage license or permit in the state where domiciled, must act within the scope of that license and any license or permit issued by the Alcohol and Tobacco Tax and Trade Bureau. 5. Within two years before making application for a direct wine seller's permit, the applicant may not have held any alcoholic beverage license or permit issued by the state of Maryland. 6. Wine that is delivered to a personal consumer in Maryland must be shipped freight prepaid to a licensed Maryland wholesaler, designated by the direct wine seller, by a public carrier holding a valid public transportation permit and a vehicle with a valid vehicle identification card, and delivered to a licensed retail dealer by the wholesaler. 7. Direct wine sellers shall list the contents of the shipment on the outside of the shipping package with an identifying number that the Maryland wholesaler shall record. 8. Direct wine sellers shall file an annual tax return which is due no later than October 15 of each year covering the twelve calendar months ending September 30. 9. During the permit year the applicant may not sell into Maryland more than 900 liters of wine or more than 108 liters of wine to a single personal consumer. 10. The term of a direct wine seller's permit begins on November 1 and expires on October 31 of the following year. 11. See Administrative Release No. AB-21 for additional information and requirements. Section 6 - Instructions 1. Submit the $10.00 annual permit fee with the application. 2. Section 3 -- Affidavit of Designated Wholesaler -- must be completed before the application can be submitted for approval. 3. Incomplete applications will be rejected and returned. If additional space is needed for any section, attach a separate sheet 4 American LegalNet, Inc. www.FormsWorkflow.com