Fillable 369-1 CLASS C SPECIAL LICENSE APPLICATION FOR MARYLAND (Comptroller of Maryland)

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369-1 CLASS C SPECIAL LICENSE APPLICATION FOR MARYLAND (Comptroller of Maryland)

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The 369-1 CLASS C SPECIAL LICENSE APPLICATION FOR MARYLAND (Comptroller of Maryland) form is 2 pages long and contains:

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COM-FED/RLS-369-1 Revised 09/19
APPLICATION FOR
CLASS C
SPECIAL LICENSE
MARYLAND
FORM
369-1
1 2 3
Name
Residence
Cell Phone
Date of Birth
Place of Birth
Social Security Number *
* The disclosure of applicant’s Social Security Number is mandatory and will be used for background investigations, including a
criminal history records checks, pursuant to the Annotated Code of Maryland, Alcoholic Beverages Article.
OFFICE USE ONLY
Check Number __________
Amount $ _____________
Deposit Date____________
License # ______________
Date Issued ____________
Approved ______________
Date _________________
To the Comptroller of Maryland:
Application is made by the undersigned under the provisions of the Annotated Code of Maryland,
Alcoholic Beverages Article, for Special Class C License for use on the following (check one):
Boat / Name of Boat ________________________________________________________
Plane / Name of Airline ______________________________________________________
Train / Name of Railroad _____________________________________________________
Check one:
Beer - $5.00 per day
Beer and Wine - $10.00 per day
Beer, Wine and Liquor - $15.00 per day
I (we) submit and certify to the following information and statements as required by the Annotated
Code of Maryland, Alcoholic Beverages Article.
1. APPLICANTS *
2. The club, society or association on behalf of which the license is desired:
Name ________________________________________________________________________________________________
Address _______________________________________________________________________________________________
FederalIdenticationNumber
-
isoperatedexclusivelyforeducational,social,fraternal,patriotic,politicalorathleticpurposesandnotforprot.
3. Are the applicants citizens of the United States, and over 21 years of age? ........................... Yes No
4. Have the applicants ever been convicted of a felony? .......................................... Yes No
5. Have the applicants ever had a license for the sale of alcoholic beverages revoked? .................... Yes No
6. Have the applicants ever been adjudged guilty of violating the law for the prevention of gambling in the state
of Maryland and/or adjudged guilty of violating the laws governing the sale of alcoholic beverages in the state
of Maryland or the United States? .......................................................
Yes No
COM-FED/RLS-369-1 Revised 09/19
APPLICATION FOR
CLASS C
SPECIAL LICENSE
MARYLAND
FORM
369-1
Page 2
The applicants submit herewith a statement duly executed and acknowledged by the company on whose behalf the license is desired,
assenting to the granting of the license applied for, authorizing the Comptroller, his duly authorized deputies, inspectors and clerks,
to inspect and search, without warrant, the boat, plane or train to which such license applies, at any and all hours, provided no such
inspection or search shall be made at such time or in such manner as to delay or interfere with movement of said boat, plane or train.
The license for which this application is made is to be for the following days(s) ____________________________________________
________________and the applicant tenders here with the sum of ( per day) $ ____________ in payment for the license.
Signature of applicant
Signature of applicant
Signature of applicant
Statement of Company Required in Connection with Annotated Code of Maryland, Alcoholic Beverages Article
I hereby certify that I am the owner of (Name of boat, plane, or train) _________________________________________________
_________________ named in the application made by _____________________________________________________________
__________________________________________________________________________________________________________
to the Comptroller of Maryland under the Annotated Code of Maryland, Alcoholic Beverages Article Class C Special License for the
day(s) set forth herein; and that I assent to the granting of the license applied for, and that I hereby authorize the Comptroller of
Maryland, his duly authorized deputies, inspectors and clerks to inspect and search, without warrant, any boat, plane or train to which
such license applies, at any and all hours, provided no such inspection or search shall be made at such time or in such manner as to
delay or interfere with the movement of such boat, plane or train.
Adavit
Idosolemnlydeclareandarmunderthe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 applicant Type or print name
Company Name and Title Date
Third Party Checks
Adavit
Idosolemnlydeclareandarm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Ocer Title
FederalIdenticationNumberand/orSocialSecurityNumber Date
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369-1 CLASS C SPECIAL LICENSE APPLICATION FOR MARYLAND (Comptroller of Maryland)

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Completed 14 August 2020

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