Fill - Free fillable 10-6 FUEL - ALCOHOL PERMIT APPLICATION FOR MARYLAND (Comptroller of Maryland) PDF form

COM-FED/RLS-10-6 Rev. 09/19

MARYLAND

FORM

10-6

APPLICATION FOR

FUEL - ALCOHOL

PERMIT

Oce Use Only

Number _______________

Permit Year _____________

Stub Number ___________

Approved ______________

Date __________________

Check Number __________

Check Amount $ ________

Deposit Date____________

SECTION 1

A. Permit is to be issued in the name of ____________________________________________

B. Whose telephone number is _____________________ and/or ______________________

Fax Number _______________________________

C. Mailing address ____________________________________________________________

street & number

city

county state nine digit zip code

D. List Social Security Number* .........

- -

FederalIdenticationNumber ........

* 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.

NOTE: READ INSTRUCTIONS CAREFULLY-INCOMPLETE OR INCORRECT APPLICATION WILL BE RETURNED.

E. The applicant is presently the holder of the following Alcoholic Beverages Permits or Licenses issued by the State of Maryland, any

other State or the United States Government (if additional space is needed, attach separate paper). If NONE, so state.

Issuing Authority Type Expiration Date Number

____________________________ ___________________________ ________________ _______________

F. Has the applicant ever been convicted of a felony by any State or Federal Court? ...................... Yes No

G. 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 in under this permit? ................................

Yes No

H. Does the applicant authorize the Comptroller of Maryland and his duly authorized personnel to search without

warrant any vehicle, railroad cars, vessel, aircraft or premises used in the business to be conducted under this

permit at any and all hours agreeable to the laws of the State of Maryland? ..........................

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? .........................................

Yes No

(Ifyes,explainindetailonaseparatepaper-listoense,court,date,etc.)

J. The Annotated Code of Maryland, Alcohol 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):

a. the applicant is not an employer required to provide coverage by the Maryland Workmen’s Compensation Law; or

b. the applicant is an employer required to provide coverage by the Maryland Workmen’s Compensation Law and has

secured such coverage. As evidence of such coverage, the following is submitted:

1. Name of Insurance Co. _____________________________________________________

2. Policy or Binder No. ________________________________________________________

COM-FED/RLS-10-6 Rev. 09/19

MARYLAND

FORM

10-6

APPLICATION FOR

FUEL - ALCOHOL

PERMIT

Contact 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

Page 2

SECTION 3

I certify under penalty of perjury that the aforementioned statements are true and correct to the best of my knowledge and belief.

I further certify that alcohol produced under this permit will be used exclusively for fuel purposes and not for beverage purposes.

Iagreetolereportsasmayberequiredfromtimetotimeandunderstandthatfailuretodosomayresultinthesuspensionor

revocation of my permit.

Signature of Applicant Date of Application

SECTION 2

A. If premises is in MARYLAND give EXACT site location (do not give P.O. address)

street & number

city state nine digit zip code

B. Physical description of premises applied for (see instructions) _____________________________________________________

C. The premises is owned by _________________________________________________________________________________

D. Whose mailing address is _________________________________________________________________________________

E. (I) (We) certify that (I am) (We are) the owner(s) of the above described premises, and (I) (We) hereby consent to the use of

the premises in the conduct of the business to be engaged in under the permit applied for and (I) (We) authorize the Comptroller

of Maryland and his duly authorized inspectors to inspect and search without warrant the premises so described at any and all

hours.

Type or Print Name Owner’s Signature

Company Name and Title Date

COM-FED/RLS-10-6 Rev. 09/19

MARYLAND

FORM

10-6

APPLICATION FOR

FUEL - ALCOHOL

PERMIT

SECTION 1

A) State in whose name the permit is to be issued. If applicant

is a corporation, the corporate name should be listed and

corporate ocers should be listed on a separate sheet. If

the applicant is a partnership, the permit must be issued in

the names of all partners. If an LLC, indicate the managing

members’ names on a separate sheet.

B) State the applicant’s telephone number including area code

and fax number, if applicable.

C) Indicate the address where mail will reach the applicant

showingstreetandnumberorPostOceBox,City,County,

State and nine digit Zip Code.

D) List the applicant’s Social Security Number and Federal

EmployerIdenticationNumber,ifapplicable.

E) State whether the applicant is the holder of any type of

alcoholic beverage license or permit under the authority of

the State of Maryland, the United States Government, or

any other State or subdivision thereof. If the applicant is the

holder of such a permit or license, list all such permits or

licenses in the space provided. If the applicant does not hold

any such licenses/permits, list “none”. Note: See Special

Instructions below pertaining to your federal permit for fuel-

alcohol use.

F) Indicate whether or not the applicant has ever been convicted

of a felony in any State or federal court.

G) If the applicant has ever been convicted in any State or

federal court for violation of the laws pertaining to alcoholic

beverages, gaming or gambling indicate the name under

which the applicant was convicted, the oense, the court

where the applicant was convicted and the date of conviction

on a separate piece of paper.

H) The applicant is to complete either (a) or (b) indicating his

compliance with the Maryland Workmen’s Compensation

Law.

SECTION 2

A) Indicate the exact site location of the permit premises

showing street or number, if any, or if none, indicate the

distance and direction of the nearest prominent landmark.

Also, show the City and County where the premises is

located.

B) Indicate the physical description of the premises.

C) Indicate the owner of the permit premises and his mailing

address. If the applicant is the owner, so state.

D) List the mailing address of the owner.

E) The owner of the premise’s signature at the bottom of this

applicationsigniestheirconsenttothesearchwithouta

warrant of any premises which are used in the conduct of

the business engaged in under this permit at any and all

hours by the Comptroller of his duly authorized personnel.

Note: Section 2 of this application must also be completed.

SECTION 3

The applicant’s signature at the bottom of the application

indicates their willingness to conform to all the laws of the

State of Maryland and any rules or regulations which have

been or may hereafter be promulgated concerning alcoholic

beverages generally and this class of permit particularly.

SPECIAL NOTES FOR FUEL-ALCOHOL PERMIT APPLICANTS

A) Attached to this application must be a copy of your federal

permit to operate a fuel-alcohol operation. If you have not

obtained such a permit, then submit a copy of your application

for same and submit copy of permit when received. This

oce will not issue a fuel-alcohol permit before evidence

is presented that you have obtained a Federal Fuel-Alcohol

permit.

B) There is no fee for this type of permit. The duration of

the permit is perpetual unless the permit is suspended or

revoked by the Comptroller.

C) As a permittee, you will be required to comply with certain

requirements of this oce. Please refer to ADDITIONAL

INFORMATION below for complete details.

D) Any questions pertaining to this permit application or the

activities thereunder should be directed to the Regulatory &

Licensing Section at (410) 260-7314.

ADDITIONAL INFORMATION

The holder (or potential holder) of a Fuel-Alcohol Permit shall be

aware of and comply with the following:

A) Before a permit will be issued by the Field Enforcement

Division, Regulatory & Licensing Section, evidence must be

made a part of the Application Form 10-6 that the applicant

holds a federal Fuel-Alcohol Permit. This shall be in the form

of a copy of the actual permit or authorization letter.

B) Each application is subject to an investigation by

representatives of the Field Enforcement Division prior to

issuance. In any event, prior to initiating operations under

this permit, a 48-hour notice shall be given to the Field

Enforcement Division (410-260-7388), so that they may

arrange to have an authorized representative on the site at

that time.

C) A yearly report of your activity is required. Report Form

COM/FED/RLS-22 covering activity between November 1

through October 31 of each year (or that portion of the year

youheldapermit)mustbeledbyNovember15annually.

Thisformmustbeledevenifyouhadnoactivityunderyour

permit duringyourreport period. Failure to le this report

on a timely basis will subject your permit to suspension or

revocation.

D) Fuel-Alcohol Permits do not expire. They will continue

in eect until suspended, revoked or you are otherwise

notiedbytheComptroller.Permitsnolongerneededshall

be immediately returned to the Field Enforcement Division,

Regulatory & Licensing Section for voluntary cancellation.

INSTRUCTIONS FOR COMPLETING

Page 3

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