Fillable Form 753: ALCOHOL AWARENESS PERMIT APPLICATION MARYLAND FORM (Comptroller of Maryland)

Fill Online, Printable, Fillable, Blank Form 753: ALCOHOL AWARENESS PERMIT APPLICATION MARYLAND FORM (Comptroller of Maryland) Form

Use Fill to complete blank online COMPTROLLER OF MARYLAND (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 753: ALCOHOL AWARENESS PERMIT APPLICATION MARYLAND FORM (Comptroller of Maryland)

On average this form takes 25 minutes to complete

The Form 753: ALCOHOL AWARENESS PERMIT APPLICATION MARYLAND FORM (Comptroller of Maryland) form is 4 pages long and contains:

  • 0 signatures
  • 24 check-boxes
  • 90 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Comptroller of Maryland

BROWSE COMPTROLLER OF MARYLAND (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MARYLAND
FORM
753
ALCOHOL AWARENESS
PERMIT APPLICATION
COM/FED RLS 753 Rev. 09/19
Section 1 - All Applicants Must Complete This Section
New Permit Renewal (give old permit no.)
Oce use only
Oce Use Only
Check #_________________
Check Amount $ __________
Deposit Date _____________
Permit # ________________
Year ____________________
Stub # __________________
Date ____________________
Issue ___________________
Approved ________________
Approval Date ____________
Note: Read instructions carefully. Incomplete or incorrect applications will be returned. File a
separate application for each type of permit desired. All permits expire October 31 annually.
Check the type of permit you are applying for (select only one):
Alcohol Awareness Program Permit Annual fee $15.00
Alcohol Awareness Instructor Permit Annual fee $ 5.00
Issuing authority Type Expiration Date Number
Program Permit is to be issued in the name:
Instructor Permit is to be issued in the name:
Daytime telephone number: FAX:
E-mail address:
Program’s address:
Instructor’s address:
The applicant is presently the holder of the following Alcoholic Beverages Permits or Licenses issued by the state of Maryland,
any other state, and/or the United States Government (if additional space is needed, attach separate paper). If NONE, so state.
A.
B.
C.
D.
E.
F.
(*) Street and number
City County State Nine-Digit Zip Code
(*) Street and number
City County State Nine-Digit Zip Code
(*) If the address is a P.O. Box or mailing address, please also provide physical location address
Applicant is a Corporation
List Federal Identication Number
-
Limited Liability Co.
Partnership
List Social Security Number*
-
Individual
* The disclosure of applicant’s Social Security Number is mandatory and will be used for background investigations pursuant to the Annotated Code of Maryland, Alcoholic
Beverages Article.
-
MARYLAND
FORM
753
ALCOHOL AWARENESS
PERMIT APPLICATION
COM/FED RLS 753 Rev. 09/19
Section 2 - Alcohol Awareness Instructor Applicants Must Complete This Section
A. Are you authorized by an Alcohol Awareness Program administrator to conduct training classes for an
Alcohol Awareness Program? (If yes, attach copy of authorization letter or program certicate and program
administrator must complete Section 6 of this application.) ......................................
Yes No
B. Attach letter listing your background and qualications as an alcohol awareness program instructor to
include a list of uently spoken languages, if this program is to be instructed in a language other than English.
Section 3 - Alcohol Awareness Program Applicants Must Complete This Section
New or revised programs must provide a hard copy of the course outline (classroom or online) with the proposed eective date,
instructor’s syllabus, testing component, sample student certicate, any other participant handouts.
A. Does your program include a section on determining the lawful drinking age of a consumer? ..............
Yes No
B. Does your program include instruction on how alcohol aects a person’s:
1. Body? .........................................................................
Yes No
2. Behavior? ......................................................................
Yes No
C. Does your program include education on the dangers of drinking and driving? .........................
Yes No
D. Does your program include eective ways to:
1. Minimize a customer’s chances of intoxication? ............................................
Yes No
2. Cease service before customer becomes intoxicated? ........................................
Yes No
3. Identify previously intoxicated customers and how to handle them? ..............................
Yes No
E. Do you have training for your alcohol awareness instructors? (If so, attach brief description. Also attach a list of
instructor names and corresponding approved Maryland permit numbers authorized to teach this program.) ...
Yes No
F. Has your program material been modied since the Division’s last approval? (If so, submit updated material
with a proposed eective date.) .........................................................
Yes No
Page 2
G. Has the applicant ever been convicted of a felony by any state or federal court? .......................
Yes No
H. Does the applicant agree to conform to all the laws, rules and regulations of the state of Maryland relating to
the business in which the applicant proposes to engage under this permit? ...........................
Yes No
I. Has the 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? (If yes, explain in detail on separate paper - list
oense, court, date, etc.) .............................................................
Yes No
J. 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 permit by this oce.
The applicant hereby arms (complete one):
Applicant is not or 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 ____________________________________________________________
2. Policy or Binder No. ____________________________________________________________
Section 1 - Continued - All Applicants Must Complete This Section
MARYLAND
FORM
753
ALCOHOL AWARENESS
PERMIT APPLICATION
COM/FED RLS 753 Rev. 09/19
Section 4 - Alcohol Awareness Program Applicants Must list any alcohol awareness program oered in the State of
Maryland
Program Title: ________________________________________________
E
X
A
M
P
L
E
Version: __________________________________________________
Most current revision date: ___________________________________
Allotted time for presentation: _________________________________
Format of Available Languages: ________________________________
Face to face proxy testing component required:
Yes
No
Method of delivery?
Classroom
Internet: Website Address ____________________________
Other
Intended Audience:
Group
Individual
Online
Oce Use Only
Approved
Disapproved
Date of Decision: ______________
Permit Year: __________________
A.
Version: __________________________________________________
Most current revision date: ___________________________________
Allotted time for presentation: _________________________________
Format of Available Languages: ________________________________
Face to face proxy testing component required:
Yes
No
Method of delivery?
Classroom
Internet: Website Address ____________________________
Other
Intended Audience:
Group
Individual
Online
Oce Use Only
Approved
Disapproved
Date of Decision: ______________
Permit Year: __________________
B.
Version: __________________________________________________
Most current revision date: ___________________________________
Allotted time for presentation: _________________________________
Format of Available Languages: ________________________________
Face to face proxy testing component required:
Yes
No
Method of delivery?
Classroom
Internet: Website Address ____________________________
Other
Intended Audience:
Group
Individual
Online
Oce Use Only
Approved
Disapproved
Date of Decision: ______________
Permit Year: __________________
C.
Version: __________________________________________________
Most current revision date: ___________________________________
Allotted time for presentation: _________________________________
Format of Available Languages: ________________________________
Face to face proxy testing component required:
Yes
No
Method of delivery?
Classroom
Internet: Website Address ____________________________
Other
Intended Audience:
Group
Individual
Online
Oce Use Only
Approved
Disapproved
Date of Decision: ______________
Permit Year: __________________
Page 3
ON PREMISE
7/1/2006
3 HOURS
ENGLISH AND SPANISH
X
X X
WWW.EXAMPLE.COM
X
MARYLAND
FORM
753
ALCOHOL AWARENESS
PERMIT APPLICATION
COM/FED RLS 753 Rev. 09/19
Section 5 - All Applicants Must Complete This Section
Adavit
I do solemnly declare and arm under the penalties of perjury that the contents of the foregoing document(s) are true and correct
to the best of my knowledge, information, and belief.
_________________________________________________ __________________________________________________
Signature of Applicant Type or Print Name of Applicant
_________________________________________________ __________________________________________________
Title Date
Section 6 - Approved Program Administrator Must Complete This Section for Alcohol Awareness Instructor Applicants
I authorize the alcohol awareness instructor applicant to conduct all(*) versions of the program named below
and approved by the Comptroller.
Yes No
(*) If authorization is limited to specic versions, please specify which versions are approved:
______________________________________________________________________________________________________
I understand that I am responsible for this instructor’s activities under this permit, and that if this instructor violates alcoholic
beverages laws or regulations, or conducts a training course contrary to the one approved and on le with the Field Enforcement
Division, Regulatory & Licensing Section, the alcohol awareness program permit may be subject to administrative action, including
suspension or revocation.
Signature (*) must be the same individual who signed the Alcohol Awareness Program Permit Application for the
current permit year.
Signature (*) Type or Print Administrator Name
Title Date
Name of Licensed Program
Program Address
Telephone Number Alcohol Awareness Program Permit Number
Page 4
If additional space is needed for any section, attach separate sheets.
INCOMPLETE APPLICATIONS WILL BE RETURNED TO YOU UNPROCESSED.
FOR MORE 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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 753: ALCOHOL AWARENESS PERMIT APPLICATION MARYLAND FORM (Comptroller of Maryland)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document