Form 363 - Maryland Common Carrier Direct Wine Shipment Report - 2013
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1
2
3MARYLAND COMMON CARRIER
2013
FORM
363
DIRECT WINE SHIPMENT REPORT
Common Carrier’s Corporate Name and Trading As (T/A) Name
Federal Employer ID Number (FEIN)
-
Street Address
City
State
Zip Code
Email Address
Common Carrier Permit Number
For Calendar Quarter
□
□
□
□
CC-
January – March
April – June
July – September
October - December
DELIVERY OF DIRECT WINE SHIPMENTS TO CONSUMERS IN MARYLAND
TOTAL NUMBER OF CASES OR BOTTLES OF WINE SHIPPED IN LITERS TO CONSUMERS
DURING REPORT QUARTER
1.
Size:
4L
3L
1.5L
750ml
375ml
187ml
100ml
________ ________
2.
# of Cases:
_______
_______
_______
_______
_______
_______ ________ ________ ________
3.
# of Bottles: _______
_______
_______
_______
_______
_______ ________ ________ ________
4.
Total Liters Shipped by Case or Bottle: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. _______________
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.
Print name ______________________________________________________________________
Title: Owner, Partner or Officer _____________________________________________________
Signature ______________________________________________________________________
Date ___________________________________________________________________________
COM/RAD-363
Rev. 03/13
Page 1
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