Form Com/att-753 - Alcohol Awareness Permit Application - Comptroller Of Maryland

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Office use only

Comptroller of Maryland

Number ________________

Check

MATT Regulatory Division

Number ______________

YR ____________________

P.O. Box 2999

Check

Stub No. _______________

Annapolis, Maryland 21404-2999

Amount $_____________

Date ___________________

Deposit

410-260-7381

Date_________________

Issue __________________

888-784-0145

Approval Date __________

Alcohol Awareness Permit Application

Note

•

Read instructions carefully.

•

Incomplete or incorrect

applications will be returned.

Office use only

•

File a separate application for

each type of permit desired.

•

All permits expire October 31

Annually.

Check the type of permit you are applying for (select only one):

G Alcohol Awareness Program Permit

Annual fee

$15.00

G Alcohol Awareness Instructor Permit

Annual fee

$ 5.00

Use typewriter or print in in

Section 1 - All Applicants Must Complete This Section

G New Permit

G Renewal (give old permit no.)

Program Permit is to be issued in the name:

Instructor Permit is to be issued in the name:

Last

First

M.I.

Daytime telephone number:

Area Code or 800

(

)

FAX: (

)

E-mail address:

Program’s address:

(*) Street and Number

City

County

State

Nine-Digit ZIP CODE

Instructor’s address:

(*) Street and Number

City

County

State

Nine-Digit ZIP CODE

(*) If the address is a P.O. Box or mailing address, please also provide physical location address

Applicant is a:

Corporation

}

List Federal Identification No.

–

Limited Liability Co.

Partnership

}

List Social Security No.*

–

Individual

* The disclosure of applicant’s Social Security Number is mandatory and will be used for background investigations pursuant to Article 2B of the Annotated Code of Maryland.

The applicant is presently the holder of the following Alcoholic Beverages Permits or Licenses issued by the State of Maryland, any other

state, and/or the United States Government. (If additional space is needed, attach separate sheet.) If NONE, so state.

Number

Issuing Authority

Type

Expiration Date

COM/ATT-753

Rev. 7-07