Maryland Form PERMIT APPLICATION 328 Comptroller of Maryland Field Enforcement Division Regulatory and Licensing Section P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7314 or 800-MD-TAXES www.marylandtaxes.com Office use only Note:· Readinstructionscarefully.Incompleteorincorrectapplicationwillbereturned. · Fileaseparateapplicationforeachtypeofpermitdesired. · AllapplicantsmustcompleteSections1and10. · AllrenewalapplicationsreceivedafterOctober31mustbeconsiderednewapplications. Check the type of permit you are applying for: (See last page for explanation) ND-Non-Resident Dealer NS-Non-Resident Storage IE-Import-Export PT-Public Transportation NW-Non-Resident Winery NB-Non-Resident Brewery $200.00 $500.00 $75.00 $75.00 $50.00 $50.00 IT-Individual Transportation IS-Individual Storage PS-Public Storage ST-Storage & Transportation $10.00 $50.00 $75.00 $200.00 CD-Change of Domicile NC-Non-Beverage "C" NE-Non-Beverage "E" VehicleIdentificationCard(each) RD-Resident Dealer $ 5.00 $50.00 Gratis $10.00 $ 200.00 FP-Family Beer and Wine Facility $400.00 NL-Non-Resident Distillery $100.00 Section 1 - All Applicants Must Complete This Section New Permit Renewal (permit no.) ________________ A. Permit is to be issued in the name of ________________________________________________________________________ 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 Alcoholic Beverages Article. ListFederalIdentificationNumber - List Social Security Number* (Required for Resident Dealers) * The disclosure of applicant's Social Security Number is mandatory and will be used for background investigations pursuant to 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 Type Expiration date Number COM-FED/RLS-328 Rev. 08/16 American LegalNet, Inc. www.FormsWorkFlow.com Maryland Form PERMIT APPLICATION Page 2 328 G. Has the applicant ever been convicted of a felony by any state or federal court? . . . . . . . . . . . . . . . . . . . . . . . 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Yes No 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? . . . . . . . . . . . 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.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Yes Yes No No L. The Alcoholic Beverages Article of the Annotated Code of Maryland titled "Workers' Compensation Compliance" requirestheevidenceofsuchcompliancepriortotheissuanceofanypermitbythisoffice. Theapplicantherebyaffirms(completeone): a. b. Applicant is not an employer required to provide coverage by the Maryland Workers' Compensation Law; or 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 & 10 A. Alcohol purchased under this permit is to be used for ___________________________________________________________ B. Iftheapplicantisahospital,educationalorcharitableorganizationqualifiedforNon-Beverage"E"gratispermit,setforththe nature of the organization and operation. ______________________________________________________________________________________________________ Section 3 - Change of Domicile Permit Applicants Complete This Section in Addition to Sections 1 & 10 A. I am changing my domicile and moving my household effects from Street and Number City County State Nine - digit ZIP Code Country Country Code to Street and Number City County State Nine - digit ZIP Code 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 and Family Beer and Wine Facility Applicants Complete This Section in Addition to Section 1 & 10. Non-Beverage Applicants Complete This Section in Addition to Section 1, 2 & 10. Public Storage and Transportation Applicants Complete This Section in Addition to Section 1, 5 & 10. A. If premises is in Maryland give exact site location (do not give P.O. address). Street and Number City County 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) C. The premises is owned by _________________________________________________________________________________ D. Whose mailing addres