Fillable Form 369: CLASS E, F OR G LICENSE (Comptroller of Maryland)

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Form 369: CLASS E, F OR G LICENSE (Comptroller of Maryland)

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APPLICATION FOR
CLASS E, F OR G LICENSE
MARYLAND
FORM
369
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
class license indicated above, and the applicant(s) submit(s) and certify(ies) to the following information required by the article.
Application may be made by any three ocers, or three employees residing in this state, duly authorized by the corporation to apply
for the license.
1. Applicants
1 2 3
Name
Residence
Home Phone
Date of Birth
Place of Birth
Social Security (*)
Title or Position
held in Organization
MD Resident Since:
NOTE: Renewal applications must be received no later than March 31.
Application for a Beer, Wine and Liquor License:
Class: E
WATER VESSEL CLASS - $150.00 license fee
F
RAILROAD CLASS - $200.00 license fee
G
AIRPLANE CLASS - $200.00 license fee
Check one: New License Renewal of License Number ______________________
Check one: Partnership Corporation Limited Liability Co. Individual
Note: Beer, Wine and Liquor License is only available to boats transporting for hire passengers from
ports in Maryland to other ports in Maryland or to coastal ports in other states of foreign ports;
or boats licensed to operate tours within Maryland waterways; to operators of cars on railroads;
and to operators of airplanes.
* The disclosure of applicant’s Social Security Number is mandatory and will be used for background investigations pursuant to
Section 10-201 of the Annotated Code of Maryland, Alcoholic Beverages Article.
2. a. Name and trade name (if applicable) of company on whose behalf license is desired: ________________________________
b. Mailing address: ______________________________________________________________________________________
(street address or post oce box)
_____________________________________________________________________________________________________
(city/state, nine digit zip code)
c. Physical location if mailing address is a post oce box __________________________________________________________
(street address)
3. Usual physical location where boat is housed (dock, wharf, pier, etc.), if applicable: ___________________________________
____________________________________________________________________________________________________
4. Boat Name (if applicable) _________________________________________________________________________________
5. Phone ______________________ Fax ______________________ E-mail ___________________________________________
6. a. Date business began __________________________________________________________________________________
b. Type of accounting period (Calendar Year, Fiscal Year, etc.) _______________ Month FY begins ______________________
c. If Corporation or Limited Liability Company - date chartered _______________________ State _______________________
d. Federal Employer Identication No. _______________________________________________________________________
COM/FED/RLS-369 06/19
Oce Use Only
Check Number __________
Amount $ _____________
Deposit Date____________
Approved ______________
Date __________________
License Number _________
Stub Number ___________
Date Issued ____________
APPLICATION FOR
CLASS E, F OR G LICENSE
MARYLAND
FORM
369
7. The name and address of the owner of the boat, plane, or train ___________________________________________________
_____________________________________________________________________________________________________
8. The applicant is presently the holder of the following alcoholic beverage licenses or permits issued by Maryland, any other state or
jurisdiction, or the United States government (if more space is needed, attach additional sheet).
Issuing Authority Type Expiration Date Number
9. The applicant has previously held the following alcoholic beverage licenses or permit: _________________________________
_____________________________________________________________________________________________________
10. The applicant has applications pending for the following alcoholic beverage licenses or permits:__________________________
_____________________________________________________________________________________________________
11. Please answer each of the following questions: (attach explanation if “Yes” to “*” questions)
*A. Has any applicant ever been convicted of a felony by any State or Federal Court? .................
YES
NO
*B. Has any applicant ever been convicted of a violation of the laws of the United States, Maryland or any
other state concerning alcoholic beverages, gaming or gambling? ............................
YES
NO
*C. Has any applicant ever been denied or had revoked an alcoholic beverage license or permit? .........
YES
NO
*D. Do any of the applicants or their immediate families have an interest in a Maryland wholesale or retail
alcoholic beverage license, either issued or applied for? ...................................
YES
NO
E. Do the applicants agree to conform to all the laws, rules, and regulations of the state of Maryland
relating to the business in which they propose to engage under this license? ....................
YES
NO
F. The applicants submit herewith a statement duly executed and acknowledged by the company on
whose behalf the license is desired, assenting to the granting to the license applied for, authorizing the
Comptroller of Maryland, his duly authorized deputies, inspectors and clerks, to inspect and search,
without warrant, any and all airplanes, cars, or boats 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 any airplane, train, or boat. ...................................
YES
NO
12. The Annotated Code of Maryland, Alcoholic Beverages Article, Section 1-404 titled “Compliance with Workers’ Compensation
Act” requires the evidence of such compliance prior to the issuance of any license by this oce. The applicant hereby arms
(complete one):
(a) the applicant is not an employer required to provide coverage by the Maryland Workers’ Compensation Law; or,
(b) the 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, the following is submitted:
1. Name of Insurance Company: ______________________________________________
2. Policy or Binder Number: __________________________________________________
13. The license for which this application is made is to be for the year beginning May 1, _______ . Fee for license applied for above is
$ ___________.
If new application, do not remit license fee with application; if renewal application, remit fee with your application.
AFFIDAVIT
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 Date
Signature of applicant Date
Signature of applicant Date
Page 2
COM/FED/RLS-369 06/19
APPLICATION FOR
CLASS E, F OR G LICENSE
MARYLAND
FORM
369
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 Ocer Title
Date
14. Statement of company required in connection with the Annotated Code of Maryland, Alcoholic Beverages Article.
I HEREBY CERTIFY, That I am the owner of (name of water vessel, airplane, or railroad)
______________________________________________________________________________________________________
named in the application made by __________________________________________________________________________
______________________________________________________________________________________________________
to the Comptroller of Maryland under the Annotated Code of Maryland, Alcoholic Beverages Article for the class license indicated, expiring
April 30,_________;
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 and all airplanes, cars, or
boats 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 any airplane, train, or boat.
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 Type or print name
Title Date
Federal Identication Number and/or Social Security Number
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
Page 3
COM/FED/RLS-369 06/19
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Form 369: CLASS E, F OR G LICENSE (Comptroller of Maryland)

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Completed 14 August 2020

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