Form 637 - Cigarette And Tobacco Products (Otp) Licenses Application
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CIGARETTE AND OTHER TOBACCO
637
PRODUCTS (OTP) LICENSES APPLICATION
Name and/or Trade Name
OFFICE USE ONLY
Check Number __________
Mailing address / Street and Number
Amount $ _____________
Deposit Date____________
City
County
State
Nine - digit ZIP Code
Approved ______________
Date _________________
Office telephone number
FAX
License # ______________
(
)
or (
)
(
)
Stub # ________________
E-mail address
Date Issued ____________
Check type of license(s)desired and if new or renewal
Cigarette Licenses
OTP Licenses
Annual
Annual
Fee
Fee
TW-
PW-
$750.00
$250.00
Wholesaler #
OTP Wholesaler #
TS-
$500.00
The fee for this OTP wholesaler license is waived if you currently have
Subwholesaler #
or are applying for a Cigarette Wholesaler’s License or a Cigarette
TV-
$500.00
Subwholesaler license.
Vending Machine Operator #
TM-
$25.00
PM-
$25.00
Manufacturer #
Licensed OTP Manufacturer #
TP-
$25.00
SW-
$25.00
Storage Warehouse #
OTP Storage Warehouse #
The following only applies to Cigarette Licenses:
New Application Fee (Per Location)
$200.00
$30.00
Renewal of Existing License
(Required for new license application)
To: The Comptroller of Maryland
Application is made by the undersigned under the provisions of Title 16 and Title 16.5 of the Business Regulation Article of the
Annotated Code of Maryland as amended, for the type of license checked above, and the applicant submits and certifies to the
following information:
A. Type of Ownership
Corporation
-
}
List Federal Identification Number
Limited Liability Co.
Partnership
-
-
}
List Social Security Number*
Individual
B.
License or storage location: ____________________________________________________________________________________________
1.
Street and Number
___________________________________________________________________________________________________________________________________
City
County
State
Nine - digit ZIP Code
2. Identify and describe storage warehouse:
__________________________________________________________________________________________________________________
C. Give location where records will be available for audit in Maryland. (If different from license address, approval must be given by
this office in writing.) _____________________________________________________________________________________
D. Individual, partner(s) or corporate officers:
1
2
3
Name
Residence
Home Telephone No.
Social Security No.
Title
Attach sheet for additional partner(s) or corporate officer(s).
COM/RAD-637
Revised 06/13
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