Application is hereby made for a Mobile Food Service License in Montgomery County, Maryland.

                                                                                                                                TODAY’S DATE______________

Please Check Type: One Year License

90 Day – a total of 90 days a year with dates of operation typed on license.

List specific dates of operation: ___________________________________________________________________

Name of Business:_____________________________________________________________________________

Motor Vehicle   Trailer      M.V.A. Tag #:__________________________State:___________________________

Owner or Corporation Name:______________________________________________________________________

Federal Tax Identification #: _______________

Owner or Corporation Address:___________________________________________________________________

                                                                                Street Number and Street Name

____________________________________________________________Telephone Number:_________________

Normal Hours of Operation:______________________________________________________________________

Base of Operation Location:_____________________________________________________________________

                                                                 Name of Licensed Food Service Facility

_____________________________________________________________________________________________

Street Number and Street Name                                                         City                          State                        Zip Code

(Note: A copy of the Food Service Facility’s license and a letter permitting the applicant use of the facility as their base of operation must be submitted with the application.)

Contact Person's Name:_________________________________  Daytime Telephone:______________________

                                                                                                                                           include area code

Fax Telephone:________________________   Email Address:_________________________________________

                                include area code

Applicant’s Signature:  _________________________________________________________________________

Printed Name of Above Signature:  _______________________________________Title: ____________________
  

Payment Method   Fee Information:  See Mobile Unit Fact Sheet

Check   Money Order (No cash is accepted) Visa    MasterCard  (No other credit cards are accepted)

Organization: _________________________________Cardholder’s Name:______________________________

Credit Card No:_________________________________ Exp. Date:______________  Amt: $_______________

I agree to pay the above total amount according to the card issuer agreement.

 Cardholder’s Signature: _______________________________________________________

Submit completed application and application fee to address at the top of the application. Checks or money orders are payable to “Montgomery County, Maryland”.