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Questions? Please contact us at:

enforcement.mmcc@maryland.gov

849 International Drive, 4th Floor, Linthicum, MD, 21090, US

Change to Name, Mailing Address, or Point of Contact for Licensee/Registrant

Change to Name, Mailing Address, or Point of Contact for Licensee/Registrant

Name of person completing form:

Is this form being submitted in relation to a recently approved request to transfer ownership of a licensed entity or a license?

Select which of the following was approved by the Commission:

Will the legal name (not the trade name) of the entity holding the license change as a result of the transfer?

Check the appropritate block(s) to indicate what you are seeking to change. MMCC WILL ONLY UPDATE THE INFORMATION CHECKED BELOW. A change to the legal and/or trade name will require MMCC approval. You will be advised via email when the legal and/or trade name is approved.

The following documents (in .pdf format) must be submitted in support of a request to change the legal name of the Licensee or Registrant: 1. A copy of documentation showing that the requisite filing has been accepted by SDAT; and 2. A copy of documentation showing that the Licensee or Registrant is in good standing with SDAT.

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The following documents (in .pdf format) must be submitted in support of a request to change the trade name of the Licensee or Registrant: 1. A copy of documentation showing that the requisite filing has been accepted by SDAT; and 2. A copy of documentation showing that the Licensee or Registrant is in good standing with SDAT.

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Complete where applicable:

Payment instructions:

For changes that require MCA to print and mail a new license (marked with * above), send a check or money order payable to MCA (ATTN: Mitch Parke) to MCA’s office at 849 International Drive, Linthicum, MD 21091. Include a printed copy of this form with the check.

ATTESTATION BY PERSON SUBMITING THIS FORM:

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