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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 CSR: vvvvw.azliquor.gov (602) 542-5141 License: APPLICATION FOR SPECIAL EVENT LICENSE Fee= $25.00 per day for 1-10 days (consecutive) A service fee of $25.00 will be charged for all dishonored checks (A.R.S. § 44-6852) IMPORTANT INFORMATION: This document must be fully completed or it will be returned. The Department of Liquor Licenses and Control must receive this application ten (10) business days prior to the event. 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 (see Section 15). SECTION 1 Name of Organization: --aghaE SECTION 2 Non-Profit/IRS Tax Exempt Number: 20‘ 41 SECTION 3 The organization is a: (check one box only) EICharitableDFratemal (must have regular membership and have been in existence for over five (5) years) EIReligious MCivic (Rotary, College Scholarship) DPolitical Party, Ballot Measure or Campaign Committee SECTION 4 Will this event be held on a currently licensed premise and within the already approved premises?E]Yes adNo Name of Business License Number Phone (include Area Code) SECTION 5 How is this special event going to conduct all dispensing, serving, and selling of spirituous liquors? Please read R-19- 318 for explanation (look in special event planning guide) and check one of the following boxes. 0Place license in non-use 0Dispense and serve all spirituous liquors under retailer's license AfDispense and serve all spirituous liquors under special event 0Split premise between special event and retail location (If not using retail license, submit a letter of agreement from the agent/owner of the licensed premise to suspend the license during the event. If the special event is only using a portion of premise, agent/owner will need to suspend that portion of the premise.) SECTION 6 What is the purpose of this event? gOn-site consumption 00ff-site (auction) 0Both SECTION 7 Location of the Event: A'aeirrz t-7?R4---,4r./9,47 geN7---f -A0 Address of Location: I 4/171‘1 &-j2;146 fi) 51-W) 3 /0 /Tr 1,), ' 3R/11.0/h Az gi-1;575 Street City COUNTY State Zip SECTION 8 Will this be stacked with a wine festival/craft distiller festival? 0Yes lidNo SECTION 9 Applicant must be a member of the qualifying organization and authorized by an Officer, Director or Chairperson of the Organization named in Section 1. (Authorizing signature is required in Section 13.) 1. Applicant: FR g Last First Middle Date of Birth 2. Applicant's mailing address: 3. Applicant's home/cell phon Aonlicant's business phone: ( ) 4. Applicant's email address: 8/13/2015 Page 1 of 4 Individuals requiring ADA accommodations call (602)542-9027. SECTION 10 1. Has the appligt been convicted of a felony, or had a liquor license revoked within the last five (5) years? DYes No (Ryes, attach explanation.) 2. How many special event licenses have been issued to this location this year? (The number cannot exceed 12 events per year; exceptions under A.R.S. §4 -203.02(D).) 3. Is the organization using the services of a promoter or other person to manage the event? D'es DNo (If yes, attach a copy of the agreement.) 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 Percentage: Address Cy State Zip Name Percentage: Add(ess o Street City State Zip 5. Please read A.R.S. § 4-203.02 Soecial event license; rules and R19-1-205 Requirements for a Soecial Event Ucense. Note: ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY. "NO ALCOHOLIC BEVERAGES SHALL LEAVE SPECIAL EVENT UNLESS THEY ARE IN AUCTION SEALED CONTAINERS OR THE SPECIAL EVENT LICENSE IS STACKED WITH WINE /CRAFT DISTILLERY FESTIVAL LICENSE" 6. What type of security and control measures will you take to prevent violations of liquor laws at this event? (List type and pumber of police/security personnel and type of fencing or control barriers, if applicable.) Number of Police 7 Number of Security Personnel OFencing :larders Explanation: eZ.Z/ 46 orricF) A39E- gr E".xelf idIA/1 7-X6Z Apiov 10 SECTION 11 Date(s) and Hours of Event. May not exceed 10 consecutive days. See A.R.S. § 4-244(15) and (17) for legal hours of service. Date Day of Week Event Start License End Time AM/PM Time AM/PM DAY]: e:)e-7-0,egR I FR/b4t, 5:30 PJA, 10 =.3.0 DAY 2: DAY 3: DAY 4: DAY 5: DAY 6: DAY 7: DAY 8: DAY 9: DAY 10: 8/13/2015 Page 2 of 4 Individuals requiring ADA accommodations call (602)542-9027. 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. e 5 e- I L st- cti kt- 8/13/2015 Page 3 of 4 Individuals requiring ADA accommodations call (602)542-9027. SECTION 13 To be completed only by an Officer, Director or Chairperson of the organization named in Section 1. Ft ur-ryti2- declare that I am an OFFICER, DIRECTOR, or CHA (Print Full Name) appointing the applicant listed in Section 9, to apply on behalf of the foregoing organization for a Spe Liquor License. X 7 (Sign ore) Tffie/ Position Date The foregoing instrument was acknowledged before me this Day Month State ,42_./ 0 0,4 County of My Commission Expires on: Date Signature of Notary Pubic SECTION 14 This section is to be completed only by the applicant named in Section 9. FRAtte.e.s 7/11.Ev. declare that I am the APPLICANT filing this application as (Print Full Name) listed in Section 9. I have read the application and the contents and all statements are true, correct and /REAS1dTg (Signature) Title/ Position The foregoing instrument was acknowledged before me this ANL .47111.-.1116. ROBERTA W COMBES Notary Public - A zona My Commission Expires on: 02.0 Maricopa Cour My Comm. Expires Ap 14, 2019 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: httb://www.azliauor.gov/assets/documents/homebade docs/sbec event Iinks.pdf. SECTION 15 Local Governing Body Approval Section recommend CIAPPROVAL 0 DISAPPROVAL (Government Official) (Title) on behalf of (City. Town, County) Signature Date Phone FOR DEPARTMENT OF LIQUOR LICENSES AND CONTROL USE ONLY 0APPROVAL 0 DISAPPROVAL BY: DATE: 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 12-820.02. 8/13/2015 Page 4 of 4 Individuals requiring ADA accommodations call (602)542-9027.