Form Com/rad 383 - Common Carrier Permit Application For Direct Wine Shipment
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1
2Common Carrier Permit Application
for Direct Wine Shipment
Section 1 - Applicant Information
Office Use Only
□
□
New Permit
Renewal (Permit #) CC- __________
Number ___________________
Corporate Name and T/A of Common Carrier
Permit Year ________________
A.
Stub Number ______________
Name of Contact
Phone Number
Fax Number
Approved _________________
Date ______________________
B.
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:
□
Corporation
-
□
Limited Liability Co.
Federal Identification Number
□
Partnership
-
-
□
Individual
Social Security Number
Section 2 - Permit Information
A.
Is the applicant a business entity that holds itself out as being available to the public to transport in interstate or
□
□
Yes
No
foreign commerce for compensation any class of passenger or property? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B.
Does the applicant agree to submit to the Comptroller at the time of application, and on request, information
□
□
concerning the training of its drivers for age-verification of consumers to whom wine is delivered? . . . . . . . . . . . . .
Yes
No
C.
Does the applicant agree to conform to all the laws, rules, and regulations of the State of Maryland relating to
□
□
Yes
No
the business proposed under this permit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. D
oes the applicant agree to verify annually in a manner acceptable to the Comptroller that direct wine
□
□
Yes
No
shipments to Maryland consumers were made under valid direct wine shipper’s permits? . . . . . . . . . . . . . . . . . . .
E.
Does the applicant authorize the Comptroller of Maryland and the Comptroller’s duly authorized personnel
to search without warrant any vehicle, railroad car, vessel, aircraft, or premises used in the business to be
□
□
Yes
No
conducted under this permit at any and all hours agreeable to the laws of the State of Maryland? . . . . . . . . . . . . .
Do you agree to file quarterly reports stating the date of each delivery of wine in the State, and the name and
F.
□
□
Yes
No
address of the direct wine shipper, and the consumer who received each delivery? . . . . . . . . . . . . . . . . . . . . . . . .
Section 3 - Affidavit of Common Carrier Permit Applicant
I do solemnly declare and affirm, under penalty of perjury, that the contents of the foregoing document are true and correct to the best of my knowledge,
information, and belief.
Signature of Owner, Partner, or Corporate Officer
Type or Print Name of Owner, Partner, or Corporate Officer
Title
Date
COM/RAD 383
Rev. 6/11
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