Office Use Only Office Use Only Check Number Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax Louis L. Goldstein Treasury Building P.O. Box 2999 Annapolis, MD 21404 410-260-7327 888-784-0145 Number VID ________ YR _______ Stub # VID #’s Check Amount $ Deposit Date http://compnet.comp.state.md.us/MATT_Regulatory_Division/ Approved Permit Application Date Note: • Read instructions carefully. Incomplete or incorrect application will be returned. • File a separate application for each type of permit desired. • All applicants must complete Sections 1 and 7. • All renewal applications received after October 31 must be considered new applications. Office use only Check the type of permit you are applying for: (See back page for explanation) G ND-Non-resident Dealer G IE-Import-Export $100.00 $75.00 G IT-Individual Transportation $10.00 G CD-Change of Domicile $ 5.00 G IS-Individual Storage $50.00 G NC-Non-beverage “C” $50.00 $75.00 G NE-Non-beverage “E” Gratis G Vehicle Identification Card $ 10.00 each G NS-Non-resident Storage $500.00 G NW-Non-resident Winery $50.00 G PS-Public Storage G ST-Storage & Transportation $100.00 G PT-Public Transportation $75.00 G FP-Family Beer and Wine Facility $400.00 Section 1 - All Applicants Must Complete This Section G New Permit G Renewal (give permit no.) A. Permit is to be issued in the name Corporate name for corporation; all partners if partnership; individual name and trade name B. Whose telephone number is (___) or (___) FAX (___) Toll Free Number E-mail address C. Whose mailing address is Street and Number City County State Nine - digit 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 G ¤ List Federal Identification Number – G G ¤ List Social Security Number* – – * The disclosure of applicant’s Social Security Number is mandatory and will be used for background investigations pursuant to Article 2B of the Annotated Code of Maryland. F. The applicant is presently the holder of the following Alcoholic Beverages Permits or Licenses issued by any other state, the state of Maryland, or the United States Government (if additional space is needed, attach separate paper). If NONE, so state. Issuing authority COM/ATT-010 Rev. 9/07 Type Expiration date Number (continued on next page) American LegalNet, Inc. www.FormsWorkflow.com G. Has the applicant ever been convicted of a felony by any state or federal court? ................................................. G Yes G No H. 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 I. Does the applicant authorize the Comptroller of Maryland and the comptroller’s 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 J. 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.) ....................................................................................................................................... G Yes G No K. Does the applicant have an interest in a Maryland alcoholic beverage wholesale or retail license, either issued or applied for? Provide particulars on separate attachment.................................................................................. G Yes G No L. 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): 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. Section 2 - Non-beverage Applicants Complete This Section in Addition to Sections 1, 4, & 7 A. Alcohol purchased under this permit is to be used for B. If the applicant is a hospital, educational or charitable organization qualified for non-beverage “E” gratis permit, set forth the nature of the organization and operation. Section 3 - Change of Domicile Permit Applicants Complete This Section in Addition to Sections 1 & 7 A. I am changing my domicile and moving my household effects from Street and Number City Country State Nine Digit Zip Code Street and Number City Country State Nine Digit Zip Code to B. Attach an inventory of the alcoholic beverages you wish to bring into this state showing container size, brand name, type and proof or alcoholic content. Maryland tax at the following rates should accompany this application: Wine 40 cents per gallon, Beer 9 cents per gallon, Distilled Spirits (alcoholic beverages other than wine or beer) $1.50 per gallon up to 100 proof plus .015 cents per 1 proof over 100 proof. Section 4 - Public Storage, Individual Storage & Family Beer and Wine Facility Applicants Complete This Section in Addition to Sections 1 & 7.Non-beverage Applicants Complete This Section in Addition to Sections 1, 2, & 7. Public Storage and Transportation Applicants Complete This Section in Addition to Sections 1, 5, & 7. A. If premises is in Maryland give exact site location (do not give P.O. address). Street and Number City Country State Rear, Front, 2nd Floor, etc. Other site locations B. Physical description of premises applied for (give distance to nearest prominent landmark and specify which portion of the building is to be covered by the permit if all of structure is not covered) (Section 4 continues at the top of the next page) American LegalNet, Inc. www.FormsWorkflow.com 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 the comptroller’s duly authorized inspectors to inspect and search without warrant, the premises so described at any and all hours. WITNESS (My) (Our) hand(s) and seal(s) this day of 20 (L.S.) WITNESS Owner’s signature WITNESS (L.S.) Owner’s signature Section 5 - Public Transportation, Public Storage & Transportation, Individual Transportation Applicants Complete This Section in Addition to Sections 1 & 7. A. Will you operate as a public carrier transporting for other persons? .................................................................... G Yes G No B. If your answer to question A. above is “Yes,” are you presently committed to transport for another person?...... G Yes G No C. Will you be the owner of the alcoholic beverages to be transported? .................................................................. G Yes G No D. If your answer to question C. above is “Yes,” state the source and destination of the alcoholic beverages hauled. E. Each vehicle operating under a permit must carry identification. A fee of $10.00 per tractor or straight truck must accompany this application in addition to the permit fee. F. Number of vehicles requiring identification: Tractors Straight trucks Total Section 6 - Non-resident Winery Applicants Complete This Section in addition to Sections 1 & 7. A. Do you produce not more than 27,500 gallons of your own wine annually? G Yes G No Section 7 - All Applicants Must Complete This Section Affidavit I do solemnly declare and affirm under the penalties of perjury that the contents of this foregoing documents 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 If additional space is needed for any section, attach separate sheets. American LegalNet, Inc. www.FormsWorkflow.com Explanation of Permits and Fees Permit Type Purpose Fee Renewal $100 annually Oct. 31 $50 annually Oct. 31 Non-resident dealer Authorizes out-of-state dealers to sell and deliver alcoholic beverages ONLY to persons in Maryland who are authorized under Maryland law to receive them. Non-resident winery Authorizes out-of-state wineries who produce not more than 27,500 gallons of their own wine per year to sell and deliver wine to retailers in Maryland who are authorized under Maryland law to receive them. Non-resident storage May only be issued to the holder of a Non-resident Dealer Permit (both permits may be applied for at the same time). It authorizes the holder to store alcoholic beverages in a licensed Maryland Public Storage warehouse for subsequent delivery to qualified Maryland licensees and persons outside Maryland. Invoices issued by Non-Resident Dealers from out-of-state addresses must be made with any delivery to a Maryland licensee. A monthly report of activities will be required. Attach to your application a letter fully outlining your proposed activities, including source, storage location in Maryland and ultimate destination (both in and out of Maryland) of alcoholic beverages. $500 annually Oct. 31 Import-export Authorizes importation of alcoholic beverages into Maryland for storage in a licensed public warehouse for subsequent reshipment outside the state of Maryland. Alcoholic beverages imported under this permit may not be sold, consigned or delivered to any person within the state of Maryland. A monthly report of activities will be required. Attach it to your application a letter fully outlining your proposed activities, including sources, storage location in Maryland and out-of-state destinations of alcoholic beverages. $75 annually Oct. 31 Public transportation Authorizes only transportation of alcoholic beverages for the accounts of other persons, into, within, out of or through the state of Maryland. This permit does not allow selling, storing, or warehousing in Maryland. $75 annually Oct. 31 Individual transportation Authorizes the transportation from or en route through the state of Maryland of alcoholic beverages which are not for sale or delivery within this state. Title to such alcoholic beverages shall be vested in the person to whom the permit is issued. $10 annually Oct. 31 Individual storage Authorizes only the storage of alcoholic beverages which are the property of the permittee at premises not otherwise licensed. The beverages so stored may only be delivered to the premises of the license holder. $50 annually Oct. 31 Public storage Authorizes the operation of a warehouse for the storing of alcoholic beverages in Maryland for the accounts of other persons. Monthly reports will be required. $75 annually Oct. 31 Public storage and transportation Authorizes the operation of a warehouse for the storing of alcoholic beverages in Maryland for the accounts of other persons, and transportation of alcoholic beverages into, within, through and out of the state of Maryland. Monthly reports will be required. $100 annually Oct. 31 Change of domicile Authorizes holders to transport into Maryland their private stock of alcoholic beverages for personal consumption only upon the payment of the Maryland tax on alcoholic beverages when the permittee is changing domicile into the state of Maryland. $5 Valid for specific transaction Nonbeverage “C” Authorizes the holder for commercial purposes to purchase alcohol and alcoholic beverages for use in compounding or manufacturing flavoring extracts; medicinal, antiseptic or toilet preparations, or for other similar purposes; for scientific or laboratory purposes; for flavoring food products; or for sale by druggists or apothecaries upon the written prescription of a qualified physician. $50 Valid until cancelled or revoked Nonbeverage “E” This permit is the same as the Non-Beverage “C” permit, except that it is for noncommercial purposes and will be issued gratis to any publicly supported hospital, governmental or municipal institution, educational institution or charitable organization. No fee Valid until cancelled or revoked Vehicle Identification Card Each tractor unit or straight truck hauling alcoholic beverages under the authority of a $10 annually Public Transportation Permit, Individual Transportation Permit, or a Public Storage and for each Transportation Permit must carry a Vehicle Identification Card at all times when alcoholic tractor unit or beverages are being transported. The permittee shall type the vehicle make, serial number straight truck and state of registration and license number on the card assigned to the vehicle. The cards are non-transferable once assigned by the permittee and may be used only to identify vehicles owned or leased by the permittee under such terms that the permittee has absolute and exclusive use and control of the vehicle and operator. Oct. 31 Family Beer and Wine Facility Authorized to establish a facility for the production of family beer or wine by nonlicensed Maryland state consumers who are of legal drinking age. The permit holder may provide equipment , raw materials and instructions to the consumer. Except for beer or wine produced for testing the equipment and recipes or sample to consumers who have entered into contract, the permit holder may not engage in actual production or manufacture of beer or wine. All family beer and wine produced at the Family Beer and Wine Facility shall be removed from the premises by the consumer for home consumption and personal use. Oct. 31 $400 annually American LegalNet, Inc. www.FormsWorkflow.com