COM-FED/RLS 367-1 Rev. 08-19
This statement is to be attached to and made a part of the application of:
Name(s) of license applicant(s) License Number
Trade name
Present Address; Number and Street
City County State Zip Code
The NEW location for which license transfer is desired is known as:
Street Address
City County State Zip Code
Describe premises
Telephone number Fax Number Email Address Date of anticipated move
_______________________________________________________
Signature of Owner, Partner, Member or Corporate Ocer
______________________________________________________
Type or print name of Signature of Owner, Partner, Member or Corporate Ocer
______________________________________________________
Title
_____________________________________________________
Date
Statement of Owner of Premises Required in Connection with Alcoholic Beverages Law of Maryland
(I, We) hereby certify, that (I am, we are) the owner(s) of property known as __________________________________________
_________________________________________________________________________________________________________
named in the afore going application made to the Comptroller of Maryland under the Annotated Code of Maryland, Alcoholic Beverages
Article; that (I, we) assent to the granting of the license applied for, and that (I, we) hereby authorize the Comptroller of Maryland,
his duly authorized deputies, inspectors and clerks, the Board of License Commissioners of the county in which the place of business
is located, its duly authorized agents and employees, and any peace ocer of such county to inspect and search, without warrant, the
premises upon which the business is to be conducted, and any and all parts of the building(s) in which said business is to be conducted,
at any and all hours.
____________________________________________________________ ____________________________________________________________
Owner’s signature Date
____________________________________________________________ ____________________________________________________________
Type or print name of owner Company Name and Title
Fee for Change in License Location $20.00
Adavit
I do solemnly declare and arm under the penalties of perjury that the contents of the foregoing documents are true and correct to
the best of my knowledge, information and belief.
Comptroller of
Maryland
Field Enforcement Division
Regulatory & Licensing
Section
P.O. Box 2999
Annapolis, MD 21404-2999
410-260-7314 or
800-MD-TAXES
ATT@
marylandtaxes.gov
www.marylandtaxes.gov
MARYLAND
FORM
367-1
APPLICATION FOR
CHANGE IN LICENSE
LOCATION
