Form Com/rad-381 - Direct Wine Shipper'S Permit Application
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3Direct Wine Shipper’s Permit Application
Section 1 - Applicant Information
Office Use Only
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New Permit
Renewal (Permit #) DW- _________
Number ___________________
Corporate Name and T/A of Wine Manufacturer
Permit Year ________________
A.
Stub Number ______________
Name of Contact
Phone Number
Fax Number
Approved _________________
B.
Date ______________________
E-mail address
Check Number _____________
Mailing address
Check Amount $ ___________
Deposit Date _______________
C.
City
State
Zip
If the mailing address is a P.O. Box provide physical location address
D.
E. Applicant is a:
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Corporation
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Limited Liability Co.
Federal Identification Number
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Partnership
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-
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Individual
Social Security Number
Officers of Corporation, Limited Liability Company, or Partnership:
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Name
Home Address
Home Phone No.
Social Security No.
F. The applicant is a person licensed outside the State to engage in the manufacture of wine; or a holder of a Maryland
Class 3 manufacturer’s license or a Class 4 manufacturer’s license: (submit a copy of your current license(s))
State of Issuance
Type or Class
Expiration Date
License #
(attach separate sheet, if needed)
G. Section 9-104 of Article 2B of the Annotated Code of Maryland titled “Workers’ Compensation Compliance” requires the
evidence of such compliance prior to the issuance of any permit. The applicant hereby affirms (complete one):
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a. Applicant is not an employer required to provide coverage by the Maryland Workers’ Compensation Law; or
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b. Applicant is an employer required to provide employee coverage by the Maryland Workers’ Compensation Law
and has secured such coverage. As evidence of such coverage, list the name of insurance company and policy
or binder number:
Name of Insurance Company
Policy or Binder Number
COM/RAD-381
Rev. 6/11
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Parent category: Financial