Comptroller of Maryland MATT Regulatory Division Alcohol and Tobacco Tax Louis L. Goldstein Treasury Building P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7381 888-784-0145 Approved Date Permit No. Stub No. Date Issued Office use only Check Number Check Amount Deposit Date Solicitor’s Permit Application Note: Read instructions carefully. Incomplete or incorrect applications will be returned. (Use typewriter or print in ink) Permit Year Q New Permit A. Q Renewal Q Transfer Q Duplicate If renewal, transfer or duplicate give present permit number Name: B. Last First Middle Home address: C. Street and number City State Nine digit Zip code D. Home telephone number E. Social security number Date of birth List the company(ies) you represent in the state of Maryland below. If you represent more than one company, list the principal one first. The license or permit number should be the number the state of Maryland has assigned to that company. The company’s name and address should be identical to the information appearing on its Maryland license or permit. Be complete and accurate. If additional space is required attach a separate sheet. Maryland license or permit number Company name Company address Company telephone number 1. 2. 3. 4. (Complete reverse side) + , Note: Independent brokers must submit a letter from the Maryland license or permit holder they represent verifying that their company is authorized to do so. . - COM-ATT-010-5 Rev. 7/07 American LegalNet, Inc. www.FormsWorkflow.com F. G. H. Does the applicant agree to conform to all the laws, rules, and regulations of the state of Maryland relating to the business in which he proposes to engage under this permit? ............... Q Yes Q No Does the applicant agree that he or she will not furnish anything of value to a retail licensee except advertising and related items provided by Section 12-104 of Article 2B of the Annotated Code of Maryland and regulations and bulletins issued by the Comptroller? ............. Q Yes Q No Q Yes Q No Q Yes Q No Q Yes Q No Are you or any member of your immediate family listed as a retail license applicant or employed by a retail licensee, or do you have a direct or indirect financial interest in such an establishment? ........................................................................................................... If your answer to question H. is yes, attach explanation. I. Has the applicant ever been convicted of a felony by any state or federal court? ..................... If your answer to question I. is yes, explain in detail below. J. Has the applicant been convicted of a violation of the laws of the United States, Maryland or any other state concerning alcoholic beverages, gaming or gambling? ................ If your answer to question J. is yes, explain in detail below. Name Offense Court Date Affidavit I do solemnly declare and affirm under the penalties of perjury that the contents of the foregoing document are true and correct to the best of my knowledge, information and belief. Signature of applicant Date Important: The Solicitor Permit fee is $50.00. Your check made payable to “Comptroller of Maryland” should be remitted with your application. Mail or submit your application to the Annapolis office of the Alcohol and Tobacco Tax office. Applicants do not have to personally appear to obtain a permit. However, an application must be submitted and a permit issued prior to engaging in any activity authorized by a Solicitor Permit. The permit must be physically carried on your person at all times while engaging in the activity. It is preferable that applicants mail their application to the Alcohol and Tobacco office at least 10 days in advance of need. Personal appearances can only be handled with a prior appointment. Telephone area code 410-2607381 or 410-260-7327. Solicitor’s Permits Expire October 31 Annually American LegalNet, Inc. www.FormsWorkflow.com