Liquor License application draft

10/28/2025 
Page 1 of 4 
Individuals requiring ADA accommodations please call (602)542-2999 
  Arizona Department of Liquor Licenses and Control 
  https://www.azliquor.gov 
(602) 542-5141
MUST be submitted to the Department of Liquor 10 days prior to the event.
SECTION 1 
Name of Non-Profit Organization, Candidate or Political Party:  
If the event will be held on an unlicensed premises, it MUST be approved and signed by the Local Governing 
Body Before submitting to the Arizona Department of Liquor. 
LOCAL GOVERNING BODY 
SECTION 2 
Will the event be at a location with a current liquor license and within the approved and licensed area? 
Yes
No (if no skip to section 3)
If yes, MUST attach a letter of explanation/permission/suspension from the licensed location and choose ONE option below. 
Name of Licensed Location 
 Liquor License Number 

Suspend license for the duration of the Special Event; Licensee selling all alcohol without retailer involvement.
Letter of suspension required.

Dispense and serve all spirituous liquors under retailer’s license – Business operates normally, minimum of 25% of
gross revenue from alcohol sales will be donated to licensee. Letter of permission required.

Dispense and serve all spirituous liquors under special event - The special event licensee is in charge of selling alcohol
that was purchased or donated by the special event licensee. The retailers existing alcohol inventory must be kept
separate from any alcohol used during the special event. Letter of suspension required.

Split premises between special event and licensed location - Both the special event licensee and the licensed
location will conduct sales of alcohol. (These sales must be done in separate areas. If alcohol is donated or purchased
by the special event licensee, it must be in a separate area from the alcohol that is dispensed by the licensed
location.) Letter of explanation and permission required.

Off Sale only - Wine/Distilled Spirits Pull, Live or Silent Auctions – Retailer will be permitted to conduct all normal
sales and service of alcohol. Letter of permission required.
DLLC USE ONLY 
Job #: 
Date Accepted: 
 LC: 
License #: 
Date Received: 
I,  
APPROVAL  DISAPPROVAL
       Government Official 
   Title 
On behalf of 
  City, Town, County 
              Signature 
             Date 
    SPECIAL EVENT LICENSE 
APPLICATION FEE $25.00 PER DAY 
Adelante Healthcare, Inc.


10/28/2025 
Page 2 of 4 
Individuals requiring ADA accommodations please call (602)542-2999 
SECTION 3 
Applicant MUST be a member of a qualifying nonprofit organization, political party, or Government entity and 
authorized by an Officer, Director, or Chairperson of the Organization. 
1. Applicant:
Last     
      First 
   Middle 
2. Applicant’s mailing address:
    Street 
     City 
State 
Zip 
3. Applicants home/cell phone:
 Non-profit organization phone: 
4. Applicant's email address:
5. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
Yes (if yes, attach letter of explanation)  No
SECTION 4 
1. Name of non-profit organization:
2. Non-Profit/IRS Tax Exempt Number:
 Arizona Corporation Commission File #:  
     Required 
     Required 
3. If Out Of State, specify State (Attach letter of good standing):
4. Special Event Name:
SECTION 5 
5. Event Location Name:
6. Event Address:
SECTION 6 
Must list type of security and control measures will you take to prevent violations of liquor laws at this event. 
Number of Police  
 Number of Security Personnel 
Fencing 
Barriers 
Must explain security measures:  
1. How is this special event going to conduct all dispensing, serving, and selling of spirituous liquors?
Check one of the following boxes. (R-19-318)
2. How many special event days have already been issued to this organization during the current year?
On-site consumption
Off-site (auction/wine/distilled spirits pull)
Both
Bernier, Kassandra
10000 N. El Mirage Rd., El Mirage, AZ  85335
480-369-2283
623-876-4275
kbernier@elmirageaz.gov

Adelante Healthcare, Inc.
86-0377821
01284694
n/a
Fall Fiesta for El Mirage's 75th Anniversary
Bill Gentry Park
14010 N. El Mirage Rd., El Mirage, AZ  85335
2+
6

Bill Gentry Park's Courtyard Area has permanent fencing (3' block) which will be used to contain alcohol consumption within the
beer garden perimeter in the courtyard area. (4) openings and the entire fence line will be secured by (6) ProEm security and 2+ Police. See attached doc. for details. **

0

10/28/2025 
Page 3 of 4 
Individuals requiring ADA accommodations please call (602)542-2999 
SECTION 7 
SECTION 8 
1. Is the Organization using the services of a DLLC approved Special Event Contractor from the list on our website?
Yes  No If yes, please provide the Name of the Special Event Contractor:
Special Event Contractor Signature:
2. Is the organization using the services of a series 6, 7, 11, or 12 licensee to manage the sale or service of alcohol?
(Licensees who hold a series 6, 7, 11, or 12 license are automatically qualified to be a special event contractor)
Yes  No if yes, Name of Licensee:
 Liquor License #: 
3.List the name of the Organization/individual that will receive revenues:
MUST EQUAL 100 PERCENT, APPLYING NON-PROFIT MUST RECEIVE A MINIMUM OF 25% OF THE PROCEEDS. 
Name: 
 Percentage: 
Address: 
Street 
City 
State 
Zip 
Name: 
 Percentage: 
Address: 
Street 
City 
State 
Zip 
Please read A.R.S. § 4-203.02 and R19-1-205 Special event license rules and Requirements.  
Dates and Hours of Event - Days must be consecutive and may not exceed 10 days per year. 
DAYS 
DATE 
DAY OF WEEK 
EVENT START 
TIME AM/PM 
EVENT END 
TIME AM/PM 
DAY 1 
DAY 2 
DAY 3 
DAY 4 
DAY 5 
DAY 6 
DAY 7 
DAY 8 
DAY 9 
DAY 10 
10/23/2026
Friday
5:00 PM
8:00 PM
10/24/2026
Saturday
12:00 PM
8:00 PM


City of El Mirage
50
10000 N. El Mirage Rd., El Mirage, AZ  85335
Adelante Healthcare, Inc.
50
3033 N. Central Ave., Suite 145, Phoenix, AZ 85012

10/28/2025 
        page 4 of 4 
 Individuals requiring ADA accommodations please call (602)542-2999 
SECTION 9 
Licensed location diagram: The licensed premises for your special event is the area in which you are 
authorized to sell, dispense, or serve alcoholic beverages under the provisions of your license. 
 
 
Must attach a diagram of your special event showing the area where alcohol will be sold, 
served, and consumed. Must include dimensions of event area, fencing, barricades,  
or other control measures, and include positions of security personnel. 
NO ALCOHOLIC BEVERAGES SHALL LEAVE A SPECIAL EVENT UNLESS THEY ARE IN SEALED CONTAINERS FOR AN AUCTION OR 
WINE/DISTILLED SPIRITS PULL, OR THE SPECIAL EVENT LICENSE IS STACKED WITH A WINE /CRAFT DISTILLERY FESTIVAL LICENSE. 
 
 
 
SPECIAL EVENT DIAGRAM AND 
SAFETY PLAN STANDARDS 
Diagrams do not need to be overly complicated, they can be hand drawn. However, we 
do not accept photographs or aerial views that do not show the premises clearly. The 
diagram should clearly depict the special event area in relation to the entire premises. 
Each diagram must include: 
●Overview of the location
●The event area clearly outlined with black marker
●Where alcohol will be served/stored
●All entrances and exits
●Where security will be positioned
●Square footage of event area
●Show North, East, South, West
   ATTACH DIAGRAM 
Declaration: 
I, (Print Name)  
   
 , declare under penalty of perjury that I am 
authorized to submit this application. I have read the contents and to the best of my knowledge believe all statements 
made on this application to be true, correct, and complete. 
 Signature: 
Kassandra Bernier