Form Com/att-020-3a - Application For A Private Bulk Sale Permit Page 2
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2Section 3
Identify who will be the seller of the alcoholic beverages identified in the inventory attached. (Check one)
9
Sale will be made by the individual permit applicant to the buyer.
9
Sale will be made by an unlicensed agent or auction company acting on behalf of the permit applicant.
Provide name and address of entity:
Entity Name
Street Address
City
State
9-Digit Zip Code
Section 4
Indicate the intended buyer of the alcoholic beverages identified in the inventory attached. If unknown due to
9
auction, check here.
9
A Maryland resident age 21 years of age or older. (Provide name and address.)
MD
Name
Address
City
9-Digit Zip Code
9
A Maryland retail account. (Indicate name, address and type/class of alcoholic beverage license.)
MD
Entity Name
Entity Address
City
9-Digit Zip Code
Type of License (Beer/Wine/Liquor)
License Number
9
Out of state entity authorized to receive alcoholic beverages. (Attach letter from State Alcoholic
Beverage Board authorizing importation. Indicate entity name and address.)
Entity Name
Entity Address
City
State
9-Digit Zip Code
Section 5
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 Individual
Date
Type or Print Full Name
If additional space is needed for any section, attach separate sheets.
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