COM-FED/RLS-354 09/19
MARYLAND
FORM
354
RETAIL OFF-SITE
PERMIT APPLICATION
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 the permit indicated above. Chain stores are not eligible. Permit
expires December 31st annually, regardless of the eective date. Permit fee $100.00. For event
participation limitations, please refer to the Annotated Code of Maryland, Alcoholic Beverages
Article, Section 2-136.
1. Retailer license name and trade name: ____________________________________________
2. Mailing address: ______________________________________________________________
____________________________________________________________________________
3. Business Telephone no.: __________________________ _______________
4. Federal tax identication number: __________________________ _________________
5. Retail L icense No. ____________________________ Political Subdivision (count y/cit y) _______________________________________
6. Check the type of retail license held: ................................
O-Sale only
On-Sale and O-Sale
7. Does applicant agree to conform to all laws, rules, and regulations of the State of Maryland
related to the actions and business activities authorized under this permit? ......................
Yes
No
PLEASE NOTE:
The permit holder shall notify the Comptroller of the permit holder’s intention at attend an o-site event on form
386, Intent to Participate in an O-Site event. The permit holder is also required to notify the local licensing board of
the jurisdiction in which the Farmers Market or non-prot event will be held.
Contact Information
Comptroller of Maryland
Field Enforcement Division
Regulatory & Licensing
Section
P.O. Box 2999
Annapolis, Maryland
21404-2999
410-260-7314 or 800-MD-TAXES
ATT@
marylandtaxes.gov
www.marylandtaxes.gov
Adavit -
Must be signed by the retail licensee.
I do solemnly declare and arm under the penalties of perjury that the contents of this foregoing document are true and correct
to the best of my knowledge, information, and belief.
_________________________________________________ __________________________________________________
Signature Printed Name
Title:
Owner Partner Corporate Ocer
Oce Use Only
Approved ______________
Date __________________
Permit # _______________
Stub # ________________
Check # _______________
Check Amount $ _________
Deposit Date ____________
