ANTHEM ROTARY FOUNDATION REDACTED.PDF

FOR DLLC USE ONLY
Received Date:
Arizona Department of Liquor Licenses and Control
800 W Washington 5th floor Job #:
Phoenix, AZ 85007-2934
www.azliquor.gov CSR:
(602) 542-5141 License #:
APPLICATION FOR SPECIAL EVENT LICENSE
Fees: $25.00 per day for 1 - 10 days (consecutive) Cash Checks or Money Orders Only
A service fee of $25.00 will be charged for all dishonored checks (A.R.S § 44-6852)
MPORTANT INFORMATION: This document must be fully completed or it will be returned. Ocr 5
The Department of Liquor Licenses and Control must receive this application ten (10) business days prior to the event. 4f A e 47nt,„
SECTION 1 Applicant must be a member of a qualifying nonprofit organization, political party, or Government entity and "IC
authorized by an Officer, Director, or Chairperson of the Organization.
1 Applicant: Crump Samuel
Last First Nk tfiurttn'' Middle Date of Birth
2. Applicant's mailing address: c/o Anthem Law 4210 Anthem AZ 85086
3. Applicant's home/cell phone: City St) State Zip
Applicant's business phone: ( ( 623 623 ) 661 551 -6467 - 5457
4. Applicant's email address:
SECTION 2 Name of Organization, Candidate or Political Party/Gov.: Anthem Rotary Foundation/Rotary Club of Anthem
Name of Licensed Contractor (if any):
SECTION 3 Non-Profit/IRS Tax Exempt Number: 47-0930766 / 26-00640058
SEcTION 4 Event Location: Anthem Park
Event Address: 41703 N. Gavilan Peak Pkwy, Anthem, AZ 85086
SECTION 5 Dates and Hours of Event. Days must be consecutive but may not exceed 10 consecutive days.
See A.R.S. § 4 -244(15) and (17) for legal hours of service.
PLEASE FILL OUT A SEPARATE APPLICATION FOR EACH "NON-CONSECUTIVE" DAY
Date Day of Week Event Start License End
lime AM/PM Time AM/PM
DAY 1: October 20 Saturday 10:00AM 5:00PM
DAY 2: October 21 Sunday 10:00AM 4:00PM
DAY 3:
DAY 4:
DAY 5:
DAY 6:
DAY 7:
DAY 8:
DAY 9:
DAY10:
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Individuals requiring ADA accommodations call (602)542-2999

SECTION 6 What type of security and control measures will you take to prevent violations of liquor laws at this event?
(List type and number of police/security personnel and type of fencing or control barriers, if applicable.)
Number of Police Number of Security Personnel SI Fencing OBarriers
Explanation: Temporary fencing will separate alcohol sales from children & general public
SECTION 7 Will this event be held on a currently licensed premise and within the already approved premises?ElYesSINo
(If yes, Local Governing Body Signature not required)
Name of Business License Number Phone (Include Area Code)
SECTION 8 How is this special event going to conduct all dispensing, serving, and selling of spirituous liquors? Please read R-19-
318 for explanation and check one of the following boxes.
OPlace license in non-use
ODispense and serve all spirituous liquors under retailer's license
Dispense and serve all spirituous liquors under special event
E]Split premise between special event and retail location
(IF USING RETAIL LICENSE, PLEASE SUBMIT A LETTER OF AGREEMENT FROM THE AGENT/OWNER OF THE LICENSED PREMISES TO SUSPEND OR RUN
CONCURRENT WITH THE PERMANENT LICENSE DURING THE EVENT. IF THE SPECIAL EVENT IS ONLY USING A PORTION OF THE PREIVUSE.S,
AGENT/OWNER WILL NEED TO SUSPEND THAT PORTION OF THE PREMISES.)
SECTION 9 What is the purpose of this event?
On-site consumption 00ff-site (auction/wine/distilled spirits pull) Ilhoth
SECTION 10
1. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
Ekes A No Of yes, aHach explanation.)
2. How many special event days have been issued to this organization during the calendar year? 4
(The number cannot exceed 10 days per year.)
3. Is the organization using the services of a licensed contractor or other person to manage the sale or service of alcohol?
DYes o (If yes, must be a licensed contractor or licensee of series 6, 7, 11, or 12)
4. List all people and organizations who will receive the proceeds. Account for 100% of the proceeds. The organization
applying must receive 25% of the gross revenues of the special event liquor sales. Attach an additional page if necessary.
Name Anthem Rotary Foundation 100 0/0
Percentage:
Address 3655 W Anthem Way A-109, PMB 107, Anthem AZ 85086
Name
Percentage:
Address
Street City State Zip
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Individuals requiring ADA accommodations call (602)542-2999

Please read A.R.S. § 4-203.02 Special event license; rules and R19-1-205 Requirements for a Special Event License.
Note: ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY.
NO ALCOHOLIC BEVERAGES SHALL LEAVE_A SPECIAL EVENT UNLESS THEY ARE IN AUCTION WINE OR DISTILLED SPIRITS PULL
SEALED CONTAINERS OR THE SPECIAL EVENT LICENSE IS STACKED WITH WINE /CRAFT DISTILLERY FESTIVAL LICENSE,
SECTION 11 License premises 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. Please attach a diagram
of your special event licensed premises. Please show dimensions, serving areas, fencing, barricades, or other control
measures and security position.
ATTACH DIAGRAM
If the special event will be held at a location without a permanent liquor license or if the event will be on any portion of a location that is
not covered by the existing liquor license, this application must be approved by the local government before submission to the
Department of Liquor Licenses and Control. Please contact the local governing board for additional application requirements and
submission deadlines. Additional licensing fees may also be required before approval may be granted. For more Information, please
contact your local jurisdiction.
NOTARY
Samuel T Crump
I, (Print Full Name) , hereby declare that I am the APPLICANT, I have read this document
and verify the contents and all statements are true, correct and complete to the best of my knowledge.
X (Signature) State of Aln County of 11j2ift C420,
Applicant Signature the foregoing instrument was acknowledged before me this
of -i9‘e,lijer 2,0 L
My corn ii160:5y,Public. JENNIFER NICHOLE State OBLINGER of Arizona Day Niordh Year
,,u00 Court
Commission #551288
My Commission Expires
a.11.1•I111.1101 September 09, 2022 Signature of NOTARY PUBLIC
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Individuals requiring ADA accommodations call (602)542-2999

LOCAL GOVERNING BOARD
Date Received:
recommend DAPPROVAL 0 DISAPPROVAL
(Government Official) (Title)
On behalf of
(City, Town, County) Signature Date Phone
DLLC USE ONLY
A.R.S. § 41-1030. Invalidity of rules not made according to this chapter; prohibited agency action; prohibited acts by state
employees; enforcement: notice
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not
specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a
basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that
specifically authorizes the requirement or condition.
D. THIS SECTION MAY BE ENFORCED IN A PRIVATE CIVIL ACTION AND RELIEF MAY BE AWARDED AGAINST THE STATE. THE
COURT MAY AWARD REASONABLE ATTORNEY FEES, DAMAGES AND ALL FEES ASSOCIATED WITH THE LICENSE APPLICATION TO A
PARTY THAT PREVAILS IN AN ACTION AGAINST THE STATE FOR A VIOLATION OF THIS SECTION.
E. A STATE EMPLOYEE MAY NOT INTENTIONALLY OR KNOWINGLY VIOLATE THIS SECTION. A VIOLATION OF THIS SECTION IS
CAUSE FOR DISCIPLINARY ACTION OR DISMISSAL PURSUANT TO THE AGENCY'S ADOPTED PERSONNEL POLICY.
F. THIS SECTION DOES NOT ABROGATE THE IMMUNITY PROVIDED BY SECTION 12-820.01 OR 12-820.0
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Individuals requiring ADA accommodations call (602)542-2999

SECTION 12 License premises 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. The following space is to be used to
prepare a diagram of your special event licensed premises. Please show dimensions, serving areas, fencing, barricades, or
other control measures and security position.
Location: Park Stadium Softball Field. NT
Red line depicts perimeter fencing 6° high (standard softball field).
Blue area depicts entry/exit points to be giiardcE©] by M ricopa County Sheriff's
Office deputies and private security guards.
Star represents serving locations.
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Individuals requiring ADA accommodations call 16021542-9027.