Form Com/att-010-6 - Application For Fuel-Alcohol Permit
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1
2COMPTROLLER OF MARYLAND
OFFICE USE ONLY
OFFICE USE ONLY
MATT Regulatory Division
Approved
ALCOHOL AND TOBACCO TAX
Check
Date ------------------------------------------
Number
------------------------------
P.O. BOX 2999
ANNAPOLIS, MARYLAND 21404-2999
Permit
Check
Number --------------------------------------
Amount
-------------------------------
1-888-784-0145
Stub # ----------------------------------------
(410) 260-7327
Deposit
Date
______________________
FAX (410) 974-3201
Date Issued
APPLICATION FOR FUEL-ALCOHOL PERMIT
NOTE: READ INSTRUCTIONS ON REVERSE SIDE CAREFULLY-INCOMPLETE OR INCORRECT APPLICATION WILL BE RETURNED.
SECTION 1
A) Permit is to be issued in the name of................................................................................................................................................................
B) Whose telephone number is ...................................... and/or (800) - ........................................ Fax Number ...................................
C) Whose mailing address is ...............................................................................................................................................................
(street & number)
(city)
(county)
(state)
(nine digit zip code)
D) List Social Security Number*
-
-
List Federal Employee Identification Number
-
*The disclosure of applicant’s Social Security Number is mandatory and will be used for background investigations pursuant to Section 10-
201 of Article 2B of the Annotated Code of Maryland.
E) The applicant is presently the holder of the following Alcoholic Beverages Permits of Licenses issued by the State of Maryland, any other
State or the United States Government (if additional space is needed, attach separate paper). If NONE, so state.
Issuing Authority
Type
Expiration Date
Number
G No
F) Has the applicant ever been convicted of a felony by any State or Federal Court? .............................................G Yes
G) Does the applicant agree to conform to all the laws, rules, and regulations of the State of
G No
Maryland relating to the business in which he proposes to engage in under this permit? ....................................G Yes
H) Does the applicant authorize the Comptroller of Maryland and his duly authorized personnel to search
without warrant any vehicle, railroad cars, vessel, aircraft or premises used in the business to be
G No
conducted under this permit at any and all hours agreeable to the laws of the State of Maryland?......................G Yes
I) Has the applicant ever been convicted of a violation of the laws of the United States, Maryland or any
G No
other state concerning alcoholic beverages, gaming or gambling?
.................................................................G Yes
(If yes, explain in detail on a separate paper - list offense, court, date, etc.)
J) Section 9-104 of Article 2B of the Annotated Code of Maryland titled “Workmen’s Compensation Compliance”
requires the evidence of such compliance prior to the issuance of any permit by this office.
The applicant hereby affirms (complete one):
........................
(a) the applicant is not an employer required to provide coverage by the Maryland Workmen’s Compensation Law; or
........................
(b) the applicant is an employer required to provide coverage by the Maryland Workmen’s Compensation Law and has
secured such coverage. As evidence of such coverage, the following is submitted:
1.
Name of Insurance Co..................................................................................................................
2.
Policy or Binder No. ..................................................................................................................
SECTION 2
If premises is in MARYLAND give EXACT site location (do not give P.O. address)
A)
..............................................................................................................................................................................................................
(street & number)
(city)
(state)
(other site location)
B) Physical description of premises applied for (see instructions) ............................................................................................................
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 his duly authorized inspectors to inspect and search without warrant the premises so described at any and all hours.
.....................................................................................
............................................................................................
(Type or Print Name)
(Owner’s Signature)
............................................................................................
(Title)
(Date)
SECTION 3
I certify under penalty of perjury that the aforementioned statements are true and correct to the best of my knowledge and belief. I further certify
that alcohol produced under this permit will be used exclusively for fuel purposes and not for beverage purposes. I agree to file reports as may be
required from time to time and understand that failure to do so ay result in the suspension or revocation of my permit.
.........................................................................................
.............................................................................................
Signature of Applicant
Date of Application
COM/ATT-010-6
Rev. 7/07
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