Form Com/att-19-3 - Monthly Report Of Violations / Suspensions / Revocations

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i
MATT Regulatory Division
i
Comptroller of MD
Alcohol & Tobacco Tax
Monthly Report of Violations / Suspensions / Revocations
City or County: __________________ Month of: _______________ Year: _______
City/County License #: ________________Central Registration #: ________________Class of License: ________________
Corporate Name: ___________________________________Trade As Name: ______________________________________
Address of Licensed Premises:____________________________________________________Zipcode:________________
Licensee 1: ____________________ Licensee 2: _______________________ Licensee 3: __________________________
VIOLATION
DISPOSITION & PENALTY
9
Sale to Minor
________________________________________________________________________
9
Gambling
________________________________________________________________________
9
Prostitution / Obscenity
________________________________________________________________________
9
Public Welfare / Nuisance
________________________________________________________________________
9
Cooperation (Board / Police, etc.)
________________________________________________________________________
9
Refills
________________________________________________________________________
9
After Hours
________________________________________________________________________
9
Purchase from Other Than Wholesaler
________________________________________________________________________
9
________________________________________
________________________________________________________________________
9
________________________________________
________________________________________________________________________
Date of Hearing: _______________________
Remarks: _________________________________________________
________________________________________________________________________________________________________
City/County License #: ________________Central Registration #: ________________Class of License: _______________
Corporate Name: ___________________________________Trade As Name: ______________________________________
Address of Licensed Premises: _______________________________________________Zipcode:____________________
Licensee 1: ________________________ Licensee 2: _______________________ Licensee 3: _______________________
VIOLATION
DISPOSITION & PENALTY
9
Sale to Minor
________________________________________________________________________
9
Gambling
________________________________________________________________________
9
Prostitution / Obscenity
________________________________________________________________________
9
Public Welfare / Nuisance
________________________________________________________________________
9
Cooperation (Board / Police, etc.)
________________________________________________________________________
9
Refills
________________________________________________________________________
9
After Hours
________________________________________________________________________
9
Purchase from Other Than Wholesaler
________________________________________________________________________
9
________________________________________
________________________________________________________________________
9
________________________________________
________________________________________________________________________
Date of Hearing: _________________________
Remarks:__________________________________________________
__________________________________________________________
COM/ATT-19-3 7/07
See reverse for instructions
Page_____ of _____

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