Solicitors Permit Application {370-5}

370-5 Form SolIcItor'S PermIt APPlIcAtIoN Note: Read instructions carefully. Incomplete or incorrect applications will be returned. New Permit Renewal Transfer Duplicate Permit Year ______________ If renewal, transfer or duplicate give present permit number SP __________________ Name Office Use Only Number _______________ Permit Year _____________ Stub Number ___________ Home address City State 9 Digit Zip code Approved ______________ Date __________________ Date of birth Social Security Number Phone number Check Number __________ Check Amount $________ E-mail address Deposit Date____________ List the company(ies) you represent in the state of Maryland below. If you represent more than one company, list the principal one first. The license or permit number should be the number the state of Maryland has assigned to that company. The company's name and address should be identical to the information appearing on its Maryland license or permit. Be complete and accurate. If additional space is required attach a separate sheet. Maryland license or permit number Company telephone number Company name Company address 1. 2. 3. 4. Office use only Note: Independent brokers must submit a letter from the Maryland license or permit holder they represent verifying that their company is authorized to do so. COM/RAD-370-5 12-49 American LegalNet, Inc. www.FormsWorkFlow.com 370-5 2013 Form SolIcItor'S PermIt APPlIcAtIoN Page 2 1. Does the applicant agree to conform to all the laws, rules, and regulations of the state of Maryland relating to the business in which he proposes to engage under this permit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Does the applicant agree that he or she will not furnish anything of value to a retail licensee except advertising and related items provided by Section 12-104 of Article 2B of the Annotated Code of Maryland and regulations and bulletins issued by the Comptroller? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Are you or any member of your immediate family listed as a retail license applicant or employed by a retail licensee, or do you have a direct or indirect financial interest in such an establishment? . . . . . . . . . . . . . . . . . If your answer to this question is yes, attach explanation along with statement you will not solicit this account. 4. Has the applicant ever been convicted of a felony by any state or federal court? . . . . . . . . . . . . . . . . . . . . . . . If your answer to this question is yes, explain in detail below. 5. Has the applicant been convicted of a violation of the laws of the United States, Maryland or any other state concerning alcoholic beverages, gaming or gambling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If your answer to this question is yes, explain in detail below. Yes No Yes Yes No No Yes No Yes No Name offense court Date _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Affidavit I do solemnly declare and affirm 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 Date Third Party Checks I do solemnly declare and affirm 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 Officer Title Federal Identification Number and/or Social Security Number Date Important The Solicitor Permit fee is $50.00. Your check made payable to "Comptroller of Maryland" should be remitted with your application. Mail or submit your application to the Licensing and Registration Unit in the Annapolis office. Applicants do not have to personally appear to obtain a permit. However, an application must be submitted and a permit issued prior to engaging in any activity authorized by a Solicitor Permit. The permit must be physically carried on your person at all times while engaging in the activity. It is preferable that applicants mail their application to the address below at least 10 days in advance of need. Personal appearances can only be handled with a prior appointment. Comptroller of Maryland Revenue Administration Center Licensing and Registration P.O. Box 2999 Annapolis, Maryland 21404-2999 410-260-7980 or 800-mD-tAXeS from elsewhere www.marylandtaxes.com COM/RAD-370-5 12-49 Solicitor's Permits Expire October 31 Annually American LegalNet, Inc. www.FormsWorkFlow.com