Form Com/att-009-1 - Application For Class C Special License - Comptroller Of Maryland
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1
2Comptroller of Maryland
License #
MATT Regulatory Division
OFFICE USE ONLY
Stub #
Alcohol and Tobacco Tax
Check Number
Date Issued
P.O. Box 2999
Check Amount
Annapolis, Maryland 21404-2999
Deposit Date
410-260-7314/888-784-0145
Fax# 410-974-3201
Approved
Date
Application for Class C Special License
To the Comptroller of Maryland:
Application is made by the undersigned under the provisions of Article 2B of the Annotated Code of Maryland, as
amended, title “Alcoholic Beverages” for Special Class C License for use on the following (check one):
Boat 9
Plane 9
Train 9
Name of Boat
Name of Airline
Name of Railroad
Check one:
9
Beer - $5.00 per day
9
Beer and Wine - $10.00 per day
9
Beer, Wine and Liquor - $15.00 per day
I (we) submit and certify to the following information and statements as required by Article 2B.
1.
Applicant(s):
(1)
(2)
(3)
Name
Residence
Home phone
Date of birth
Place of birth
Social Security 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.
2.
The club, society or association on behalf of which the license is desired:
Name
Address
Federal Identification Number
–
is operated exclusively for educational, social, fraternal, patriotic, political or athletic purposes and not for profit.
Yes 9
No 9
3. Are the applicants citizens of the United States, and over 21 years of age?
Yes 9
No 9
4. Have the applicants ever been convicted of a felony?
Yes 9
No 9
5. Have the applicants ever had a license for the sale of alcoholic beverages revoked?
6. Have the applicants ever been adjudged guilty of violating the law for the prevention of gambling in the state of
Maryland and/or adjudged guilty of violating the laws governing the sale of alcoholic beverages in the state of
Yes 9
No 9
Maryland or the United States?
(over)
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