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Apr, Apr. 24, 2018 3:22PM GL,Stut. LA(3 / cly.,Ao..2340G F. 1/6
FOR DLLC USE ONLY
Event Date(s):
Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor Event time start/end:
Phoenix, AZ 85007-2934
www.azlinuor.gov CSR:
(602) 542-5141 license:
APPLICATION FOR SPECIAL EVENT LICENSE
Fee= 825.00 per day for 1-10 days (consecUtive)
Cash Cheeks Or Money Orders Only
A service fee of 825.00 will he charged for ail dishonored checks (A.R.S § 44-6862)
The Department of IMPORTANT INFQRMATION: This document must be fully completed or it will be returned.
event will be held at Liquor a location Licenses without and a Control must receive this application ten (10) business days prior to the event If the special
by the existing liquor license, this permanent liquor license or if the event will be on any portion of a location that is not covered
liquor licenses and Control (see Section application 12). must be approved by the local government before submission to the Department of
SECTION 1 Name of Organization: 5 0() ct, u
Name of Lice nsed C ontractor only (if any):
SECTION 2 Non-Profit/IRS Tax Exempt Number: & fl G NO5B3 no,52oT-t3eA-104a
OECTIGN a Event Location: Galin ca-b (k)4 ikv KQR_ c_stt.t4ttp_ia
Event Address: q`k.‘ Q 13") - 4Ain,b(trn 2A& QIA) Cf-5 5315
gam! 4 Applicant must be a member of the qualifying organization and authorized by an Officer, Director, or Chairperson
of the Organization.
a o
1. Applicant: dOki 12GL C.-
Last
2. A pplicant's mailing ad dress:
vny _State zi
3. Applicant's home/cell phone Applicant's business phone:
4. Applicant's email ad dress"
(Piint Full Nano) Licc C. \,1 K.--e d eciare that I am the APPLICANTfiling this application
as listed above. I have read the application and the contents and all statements are true, coirect and complete.
(AACIQ \I WY* tiVICA114
Sigjnature Trlio/ Position Date 1,110110 Number
The foregoing instrument was acknowledged before me this grUt a-0 1S-
State County of Ak1ve_tc...6,r Day Month Year
My Commission Expires on: Viti14.01* BANG
Date Moticopois. Maw Public County- -Aril gnatore of N tory Public
Expires 09/15/2021
1/12/2017 Page 1 of 5
Individuals requiring ADA accommodations call (602)642-2999
Received Time Apr, 24. 2018 3:17PM No. 4087
'Apr, 24, 2018i" 3 22 P applicarion Tor a speciai eVenT permit: me Ulmer, Director, or Chairr No. 2340re 'P. 2/6"n
— „ le Organization meets the criteria in A.R.S. § 4-203.02(E) as indicated b y Li im,iking of le el ihe
boxes below.
(1) 0 The Organization is a political party or a campaign committee supporting a candidate for public office. Please
indicate the name of the candidate that the Organization supports, the office that the candidate seeks, and the
month and year that the candidate would first fill the office if successful.
Candidate:
Name Office Month/Year
(2) Er The Organization is a non-profit entity organized in Arizona, or pursuant t6 the laws of another state that is eligible
for designation under Section 501(C) of the internal revenue code of the United States. If the Organization is
applying under option (2) as a nonprofit entity, please also INITIAL in the spaces provided next to all following
statements to indicate that, to the best of the Organization's knowledge, the following statements are correct.
To be initialed only by an Officer, Director, or Chairperson of the organization.
4N-1\1 The Organization has received a determination letter from the Internal Revenue Service ("IRS") indicating that it
is eligible for designation as a nonprofit entity under Section 501(C), eligibility or will be eligible on all days that the
special event will occur, or has a pending application with the IRS for such treatment that has not been resolved
but that will retroactively cover all days that the special event will occur. (Please provide a copy of either the IRS
determination letter or the application [without attachments] with this application).
U The Organization is not aware of any action taken by the IRS to revoke, suspend, or otherwise eliminate their
Eligibility under 501(C), or if there is a pending application, the eligibility has not received any indication that
the IRS will deny its application and has a good faith basis formed upon a reasonable inquiry into IRS regulations,
guidelines and forms that are eligible under 501(0).
The Organization understands that if there is a change in circumstances after completing this form that may
cause or has caused it to lose its eligibility under 501(C), whether before or after receiving an IRS determination
letter, that it has an affirmative duty to notify the Department of Liquor. which may lake: appropriate. (-teflon
regarding the loss of eligibility.
A M Scearce
Notary Public
To be completed only by an Officer, Director, or Chairperson of the organization. Maricopa County, Arizona
(Print Full Name) 1-:‘ SCA \.1 declare that I kryl nn nificpr, flIrtir±r tir rhairperSnn Of
theorganization_filingthis application as listed above. I have read the application and the contents and all statements are
true, correct and complete.
X (-AbGU \I kM,S0
Signature Date Phone Number .
The foregoing instrument was acknowledged before me this 3 r 4 47;) Qofg
Day Month Year
State kl2. I 2ON r County of Mikle-k COP VI --
My Commission Expires on: 0 021
Date Signature of Notary Public
;ECTION 6 Will this event be held on a currently licensed premise and within the already approved premises?DYes
Of yes, Local Governing Body Signature not required)
Name of Business license Numbe Phone (Include Area Code)
9/12/2017 Page 2 of 5
Individuals requiring ADA accommodations call (602)542-2999
Received Time Apr, 24, 2018 3:17PM No, 4087
Apr. 24. 2018 3:22PM to 2340 P 3/6
EMU How is this spe cial event going to conduct all dispensing, serving, and selling of spliituous liquors? Please re ad 13-19-
318 for explanation and ohe ck one of the following boxes,
°Place license in non-use
°Dispense and Serve all spiritu ous liquors und er retailer's license
Mispense and serve all spultuous liquors under ape Olaf event
°Spilt premise between special event and retail location
(IF USING WAIL LICENSE, PLEASE SUBMIT A LEITER OF AGREEMENT FROM THE AGENT/OWNER OF THE LICENSED PREMISES TO SUSPEND Ol?
RUN CONCURRENT WITH THE PERMANENT LICENSE DURING THE EVENT. IF THE SPECIAL EVENT IS ONLY USING A PORTION OF THE PREMISES,
AGENT/OWNER WILL NEED TO SUSPEND THAT PORTION OF THE PREMISES.)
SE CTIQN
Wh at is the purpose of this event? XOn-site consumption Off-site (auction/wine/dialled spirits pull) °Both
ALCM O_N 9
1. Has the alpzli-cant been convicted of a felony, or had a liquor license re-voiced within the last five (5) years?
°Yes IN o (ft yes, attach explanation.)
2. How many special event days have been issued to this organization during the calendar year? ,2r
(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?
OYes ON() (If yes, must be a licensed contractor or licensee of series 8,7, 11, or 12)
4. List all people and organizations who will receive the proceeds. Account for 100% of the proceeds. The organization
applying mustreceive 25% of the gross revenues of the special event liquor sales. Attach an additional page if necessary.
Name 5 CCt) () CX>1YW-3 C.:1 Percentage; k
A. d dress SC-CO Y-N,X ,P)..0,)e— 14 401 (>04 "czA,Nry\be,c,‘\ SC-tt) 06, el.5.4-15
Name Percentage:
Address
Street city state Zfp
Please read A.R.S. § 4-203.02 Special event license: rules and R19-1-205 Reaulternents for a SnecIal Event Ucertse.
Note: ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY.
WO AIX oijoup BEVERAOES SHAU, LEIkVE A SPEWAL EVENT VNIESS THEY ARE IN AUCTION INItIE OR DISTILLED SKIRTS PULL
$E/LED CONTAINERS OR THE SPECIAL EVENT LICENSE IS STACKED WITH WINE /CRAFT DISIII,I.ERY FESTIVAL LICENSE.
5. 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.)
NUmb er of Police '9 • Number of Security Personnel °Fencing °Barriers
Explanation: 1 Lai #.A AA.LA IL. •
9/12/2017 Page 3 of 5
individ uals requitin g ADA accommodations calt(602)542-2999
Received Time Apr. 24. 2018 3:17PM No. 4087
Apr. 24, 2018 3:23PM No. 2340 P, 4/6
=MUM Dates and Hours of Event. Days must be consecutive but may not exceed 10 consecutive clays.
See A.R.S. § 4,244(15) and (17) for legal hours of service.
PLEASE FILL 01.1. A SEPARAT APPLICAlloN FOR EACH IVON-CONSECUTIVE" DAY
Date Day of Week Event Start License End
Time AM/PM Time AM/PM
DAVI: 5 13/a0R, %0OckfrA prn
DAY 2:
DAY 3:
DAY 4:
DAY 5:
DAY 6:
DAY 7:
DAY 8:
DAY 9:
DAY10:
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
9/12/2017 Page 4 of 5
individ nets re quiring ADA accommodations call (602)542-2999
Recei ved Time Apr, 24. 2018 3:17PM No. 4087
Apr, 24. 2018 3:23PM No. 2340 P. 5/6
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.
0
Kuentz Recreation Center
14401 R.H. Johnson Blvd.
Sun City West
623-S4476551 tuurfE3y Mom
StVNS.V\c,- -"7:7
?Ago
waikir4g.
\ . Bock
so/
Entrcis*
Boomers Citthhouse
k,,l5
) ft - 5oftbol Stato. fieId tetWil
k\VNAV,.., "" •
.VE:•<\ \ ,
\\\WMV,.,\W:\k,,N.S2AVal rs:\‘‘, 1 ----- -
lawlOo R,ILIVald
KuontzCourlyud
As
8/5/14 Page 3 of.4
Rece i ved Ti m e Apr. 24. 2018 tr^13f-:leiTiNeNo 0137, accommodations call (602)542-9027.
Apr, 24. 2018 3:23PM No. 2340 F. 6/6
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.
SECTION 12 Local Governing Body Approval Section.
waszEmentsts"mitat„
Date Received:
recommend 0APPRO VAL 0 DISAPPROVAL
(Government Official)
On behalf of
(City, Town, County) Signature Date Phone
SECTION 13 For Department of Liquor Licenses and Control use only.
CIAPPRO VAL EIDISAPPRO VAL BY: DAM: / /
A.R.S,§41-1030. Inva idity of rules not mpde according to this chapter: Prohibited agency action: prphibitpd acts
by state emolovees; enforcement: nolo°
B. An agency shah 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 sp e cific ally authorizes the re quire m ent or condition.
D. THIS SECTION MAY BE ENFORCED IN A PRIVATE CIVIL ACTIO N AND REUEF MAY BE AWARDED A BAINST THE STATE.
THE COURT MAY AWARD REASONABLE ATTORNEY FEES, DAMAGES AND ALL FEES ASSOCIATED WITH THE LICENSE
APPLICATIO N TO A PARTY THAT PREVAILS IN AN AC110 N A GAINST THE STATE FOR A VIOLATION 0 F THIS SECTION.
E. A STATE EMPLOYEE MAY NOT INTENTIONALLY OR KNOWINGLY VIOLATE THIS sumo r$1. A VIOLATION OF THIS
SECTIO N IS CAUSE FOR DISCIPLINARY ACTIO N OR DISMISSAL PURSUANTTO THE AGEN CY'S ADOPTED PERSO NNEL POLICY.
F. THIS SECTIO N DOES NOT ABROGATE THE IMMUNITY PROVIDED BY SECTION 12-820.01 OR 12-920.02.
9112/2017 Page 5 05
Received Time Apr, 24. 2018m 3: 17PM4No. 4087 accommodations Gall (602)542-2999