Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7327 888-784-0145 Occupation Record and Financial Statement of Individual License Applicant Full name in which license is applied for (individual, partnership, corporation or limited liability company): Name of individual applicant completing form: Instructions: Complete form using typewriter or neatly in ink. This form must be filed by the individual license applicant. It is not for use by the corporation or partnership. Each applicant must complete a separate form. Both sides must be completed and the form signed. If more space is needed for any section, attach additional sheets. I. Work history - List below your complete work history for at least the last ten (10) years. Include full-time paid positions. Title of position held COM/ATT007-3 Rev. 7/07 From To Name of employer Address of employer over American LegalNet, Inc. www.FormsWorkflow.com II. Personal financial statement - List below your personal assets and liabilities. Include real estate, bank deposits, stock, bonds, personal property, loans, mortgages, etc. If none, so state. Describe assets Amount $ $ Total assets Describe liabilities Amount $ $ Total liabilities III. (a) Personal investment in business Amount to be invested by applicant: Cash $ Equipment $ Goodwill $ Other $ Total $ (b) Is applicant’s investment in business to be financed solely from assets listed in Part II above? Yes No (c) If “No” to “b”, list below the amount of additional monies to be invested in the business, the source of same and the name and address of any person who has undertaken or will undertake to advance monies to the applicant to assist in financing said business and the relationship, if any, of each person to the applicant. Amount Source Name Address Relationship The applicant whose signature appears below represents under penalty of perjury that the foregoing statements are true and agrees that they shall be made a part of the application for a license. It is understood that information reported may be used for background investigation pursuant to Section 10-201 of Article 2B of the Annotated Code of Maryland. Date Signature of applicant American LegalNet, Inc. www.FormsWorkflow.com