Form 384 - Application For A Winery Off-Site Permit
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1APPLICATION FOR A
Form
384
WINERY OFF-SITE PERMIT
Date ________________________________, 2 ________________
Office Use Only
To the Comptroller of Maryland
Number _______________
Application is made by the undersigned under the provisions of Article 2B of the Annotated Code
Permit Year _____________
of Maryland, as amended, title “Alcoholic Beverages” for the permit indicated above. The term of
the Winery Off-Site Permit is 1 year, permit expires December 31st annually. Permit fee $100.00.
Stub Number ___________
Approved ______________
1. License name and/or trade name: _______________________________________________
Date __________________
2. Mailing address: _____________________________________________________________
Check Number __________
M
Business Phone No.: ____________ License Number
___ - ___ ___ ___ ___ ___
Check Amount $ ________
Deposit Date____________
Federal Identification Number
___ ___ - ___ ___ ___ ___ ___ ___ ___
3. Do the applicants agree to conform to all laws, rules, and regulations of the State of Maryland relating to the
business in which they propose to engage under this permit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
4. Do you agree to keep Owner of Premise form at license location for 3 years or until audited? . . . . . . . . . . . . . .
Yes
No
5. Must be signed by a winery licensee.
Affidavit
I/we do solemnly declare and affirm under 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 Winery Licensee
Type or Print Name
Please note the term of this permit is one year and expires on December 31st annually. At no time will the Comptroller
send out any notices for renewal, nor is there any renewal available for this permit. It is upon the initiative of the
applicant to reapply for any new permits upon the expiration of their current permit.
Third Party Checks
Affidavit
I do solemnly declare and affirm under the penalties of perjury that the contents below are true and correct to the best of my
knowledge, and that I am authorized and empowered to issue a check and make payment for the license/permit fee on behalf of
the applicant.
Name of Corporation; Partners of Partnership; or Individual (include Trade Name)
Complete Mailing Address
Signature of Owner, Partner or Corporate Officer
Title
Federal Identification Number and/or Social Security Number
Date
Contact Information
Comptroller of Maryland
410-260-7980 or
Revenue Administration Center
800-MD-TAXES
Licensing and Registration
P.O. Box 2999
Annapolis, Maryland 21404-2999
COM/RAD-384
13-49
06/13
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