Form 637 - Cigarette And Tobacco Products (Otp) Licenses Application Page 2
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CIGARETTE AND OTHER TOBACCO
637
PRODUCTS (OTP) LICENSES APPLICATION
SECTION 1 – All applicants must complete this section. Please answer each of the following questions:
A. List all cigarette and/or OTP licenses currently held by applicant in Maryland or any other state. __________________________
______________________________________________________________________________________________________
B. Does the applicant agree to conform to all the laws, rules and regulations of the State of Maryland relating
to the business in which they propose to engage under this license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
C. Does the applicant agree to notify Licensing and Registration in writing at least 30 days prior to any change
in the officers, location or ownership of the business? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
D. Does the applicant agree that the Comptroller and his duly authorized personnel may inspect any licensed
premise or vehicle during regular business hours? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
E. Method of operation: (Not applicable to manufacturer or storage warehouse applicants.)
(Attach answers on separate sheet)
1. List all suppliers from whom you plan to purchase cigarettes and/or OTP?
2. Will the cigarettes be stamped or unstamped? If stamped, indicate stamping area.
F. Section 1-204 of the Tax-General Article of the Annotated Code of Maryland titled “Compliance With Workers’ Compensation
Laws” requires the evidence of such compliance prior to the issuance of any license by this office. The applicant hereby affirms
that the applicant (check one):
1. is not an employer required to provide coverage by Maryland Workers’ Compensation Law; or
2. is an employer required to provide employee coverage by Maryland Workers’ Compensation Law and has secured such
coverage. As evidence of such coverage, the following is submitted:
a. Name of insurance co. ______________________________________
b. Policy or binder no. ________________________________________
G. List names, titles, and telephone numbers of persons responsible for the following:
1. Filing state reports: _____________________________________________________ ( ____ ) ________________
2. Inventory and/or audit scheduling: _________________________________________ ( ____ ) ________________
3. Warehouse operations: ___________________________________________________ ( ____ ) ________________
4. Tax stamp purchases/payment: ____________________________________________ ( ____ ) ________________
Any changes in the above information should be submitted to Licensing and Registration in writing within 30 days.
SECTION 2 – Cigarette and OTP Storage Warehouse Complete this section in addition to Sections 1 and 7
Attach a separate listing of those accounts for which you plan to store cigarettes, if applicable. Also attach a separate listing of those
accounts for which you plan to store OTP, if applicable.
SECTION 3 – Cigarette Subwholesalers – Complete this section in addition to Sections 1 and 7.
A. Does the applicant agree not to sell or transfer any cigarettes to separate entities which are owned, affiliated,
or controlled by the applicant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
B. List the retailers to whom you propose to sell cigarettes.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
SECTION 4 – Cigarette Vending Machine Operators – Complete this section in addition to Sections 1 and 7
A. Attach a separate sheet listing the names and addresses of all locations at which the applicant operates cigarette vending
machines, showing the number of machines at each location.
1. Identify which machines (if any) can only be operated with a token, card, or similar device.
2. Identify which machines (if any) are located in an establishment that minors are prohibited by law from entering. Please
provide copy of city, state, or local ordinance.
3. Identify which machines (if any) are located in an establishment that is a bonafide fraternal or veteran’s organization.
B. Do all vending machines operated by the applicant meet one of the above criteria? . . . . . . . . . . . . . . . . . . . .
YES
NO
C. Sign and attach the affidavit provided verifying that all cigarette vending machines have an age of purchase decal attached.
COM/RAD-637
Revised 06/13
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