Application For An Additional License Location {367-2}

Statement of Owner of Premises Required in Connection with Alcoholic Beverages Law of Maryland(I, We) hereby certify, that (I am, we are) the owner(s) of property known as þ named in the afore going application made to the Comptroller of Maryland under the Alcoholic Beverages Law of Maryland; that (I, we) assent to the granting of the license applied for, and that (I, we) hereby authorize the Comptroller of Maryland, his duly authorized deputies, inspectors and clerks, the Board of License Commissioners of the county in which the place of business is located, its duly the business is to be conducted, and any and all parts of the building(s) in which said business is to be conducted, at any and all hours.Witness (our/my) hand(s) and seal(s) this day of , Signature of Owner of Premise STATE OF MARYLAND ss:THIS CERTIFIES, That on the day of , , before the subscriber, a of the State of Maryland, personally appeared and acknowledged the execution of the foregoing statement to be act. (Seal) STATE OF MARYLAND ss:THIS CERTIFIES, That on the day of , , before the subscriber, a of the State of Maryland, personally appeared the applicant(s) named in the afore going application, and made oath in due form of law that the statements there are true to the best of the applicant222s knowledge and belief. (Seal) APPLICATION FOR AN ADDITIONAL LICENSE LOCATIONMARYLANDFORM367-2This statement is to be attached to and made a part of the application of: Name(s) of license applicant(s)License NumberTrade namePresent Address; Number and StreetCityCountyZip CodeThe BRANCH LOCATION location for which license is desired is known as: Street AddressCityCountyZip CodeDescribe premisesTelephone NumberFax NumberEmail Address American LegalNet, Inc. www.FormsWorkFlow.com Third Party Checks 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 þ þ Licenses and Fees Wholesaler222s License Class 1 þ Beer, Wine and Liquor þ Annual Fee þ $2,000.00 Class 2 þ Wine and Liquor þ Annual Fee þ $1,750.00 Annual Fee þ $1,500.00 Annual Fee þ $1,250.00 Annual Fee þ $1,250.00 þClass 3 Beer and Wine Class 4 Beer Class 5 Wine Annual Fee þ $50.00 APPLICATION FOR AN ADDITIONAL LICENSE LOCATIONMARYLANDFORM367-2 Contact Information 4www.marylandtaxes.com Annual Fee Annual Fee $50.00 American LegalNet, Inc. www.FormsWorkFlow.com