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Affidavit of Corporate Officer for Substitution or Deletion of Licensee
Corporate/legal name of the Premises
Work Phone # Contact/Cell Phone #
STATE OF MARYLAND, COUNTY OF ANNE ARUNDEL, to wit:
I HEREBY CERTIFY, on this day of , , before me, the subscriber, a Notary
Public of the State of Maryland, in and for the county of Anne Arundel, personally appeared
(corporate officer), known by me to be the
, (officer’s title) of the aforesaid corporation, and
in his/her capacity as an officer of the corporation certified that an Application for Substitution of Officer has been filed with
the City of Annapolis Alcoholic Beverage Control Board due to the fact that
being removed), previously an officer of the Corporation, can no longer serve as a licensee on the alcoholic beverage
license because the licensee:
is deceased has been removed from office
is retired no longer holds an office in the corporation or club.
The affiant further certified that the new officer and
(officer’s title) of the corporation has been issued stock in the corporation, that the shares of stock previously issued to
(officer being removed) have been returned to the corporation, and, with
that exception, the ownership of the corporation has not changed.
Name of Corporation/LLC
I HEREBY CERTIFY, on this day of , , before me, the subscriber, a
Notary Public of the State and County aforesaid, personally appeared
and made oath in due form of law that the matters and facts set forth above are true and correct.
WITNESS my hand and Notary Seal.
Notary Public My Commission expires
Officer being removed
Office of the City Clerk
160 Duke of Gloucester Street
Annapolis, MD 21401-2517
DepClerk@annapolis.gov • 410-263-7942 • Fax 410-280-1853 • TDD use MD Relay or 711 • www.annapolis.gov