Form Com/att-10-7 - Application For National Family Beer And/or Wine Exhibition Permit Page 2
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1
2Section 3
(To be completed only if you answered “No” to question F in Section 1)
Owner of premises statement:
Physical description of premises applied for:
The premises is owned by:
Whose mailing address is:
(I/We) certify that (I am/we are) the owner(s) of the above described premises, and (I/we) hereby consent to the use of the premises in the conduct
of the business to be engaged in under the permit applied for and (I/we) authorize the Comptroller of Maryland and his duly authorized personnel
to inspect and search without warrant the premises so described at any and all hours.
WITNESS (my/ours) hand(s) and seal(s) this
Month
Day
Year
WITNESS
(L.S.)
(Owner's Signature)
WITNESS
(Owner's Signature)
Section 4 (Fees)
A.
Permit Fee:
......................................................... $ 50.00
B.
Prepayment of Taxes*:
Beer ............................... $
50.00
Wine .............................. $
Total Tax ........... $
Remitted herewith ................................................................................................. $
* Determined by estimating the number of gallons of commercially produced beer or wine to be received from non-Maryland licensed manufacturers or
suppliers and multiplying by the wine tax rate of 40¢ per gallon or the beer tax rate of 9¢ per gallon.
NOTE: Within 30 days of the close of the event, Form COM/ATT-34-11 is to be completed and submitted to the Alcohol and Tobacco Tax office.
Section 5 - All applicants must complete this section.
Affidavit
I solemnly declare and affirm under penalties of perjury that the contents of the foregoing documents
are true and correct to the best of my knowledge, information, and belief.
Signature of Applicant
(If a corporation - the president, vice-president, or secretary/treasurer)
Type or Print Name of Applicant
Title
Date
If additional space is needed for any section, attach separate sheets.
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