ANTHEM ROTARY GOLF TOURNAMENT_REDACTED.PDF

Arizona Department of Liquor Licenses and Control DLLC USE ONLY

https://www.azliquor.gov Job #:
(602) 542-5141 Date Accepted:
Lc:
SPECIAL EVENT LICENSE
APPLICATION FEE $25.00 PER DAY License #:

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: Anthem Rotary Foundation

If the event will be held on an unlicensed premises, it [\VIUST be approved and signed by the Local Governing
Body Before submitting to the Arizona Department of Liquor.

LOCAL GOVERNING BODY

Date Received:

C1 approval 1 pisapprovat

Government Official Title

On behalf of

City, Town, County Signature

SECTION 2
Will the event be at a location with a current liquor license and within the approved and licensed area?

Clyves  [YJNo (ifno 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

Ol Suspend license for the duration of the Special Event; Licensee selling all alcohol without retailer involvement.
Letter of suspension required.

OC 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.

[1 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.

CO 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.

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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:__ Salem Edward John, Jr
last
Street City State Zip

928-279-8733

3. Applicants home/cell phone: Non-profit organization phone:

5. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
Lives (if yes, attach letter of explanation) No

SECTION 4

1. Name of non-profit organization: Anthem Rotary Foundation

ATOR ESOT Zee g0e Arizona Corporation Commission File #: 109477921
Required Required
3. If Out Of State, specify State (Attach letter of good standing):

2. Non-Profit/IRS Tax Exempt Number:

4, Special Event Name:_ Anthem Rotary Golf Tournament

SECTION 5
Anthem Golf & Country Club / The Ironwood Course

5. Event Location Name:

6. Event Address; 47951 N Anthem Hills Dr, Phoenix, AZ 85086

SECTION 6

Must list type of security and control measures will you take to prevent violations of liquor laws at this event.

Nh

Number of Police 2 Number of Security Personnel []Fencing []earriers

Must explsinsecurity measures: There will be 2 Maricopa County Sheriffs deputies on foot patrol

as well as private security personel. The serving and consumption area is fenced.

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)

on-site consumption _loft-site (auction/wine/distilled spirits pull) Loth

2

2. How many special event days have already been issued to this organization during the current year?

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Individuals requiring ADA accommodations please call (602)542-2999

SECTION 7

Dates and Hours of Event - Days must be consecutive and may not exceed 10 days per year.

EVENT START EVENT END
DAYS DATE DAY OF WEEK TIME AM/PM TIME AM/PM
pay1 09/16/2026 Saturday 08:00AM 9:00 PM
DAY 2
DAY 3
DAY 4
DAY 6 &
FEB 0 6 2026
DAY 7
MARICOPA COUNTY
DAY 8 CLERK BOARD OF SUPERVISORS
DAY 9
DAY 10

SECTION 8

1. Is the Organization using the services of a DLLC approved Special Event Contractor from the list on our website?

[Wes Ino 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)

[Wes [Ino 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.

‘ . 0
Name: Anthem Rotarian Foundation Percentages [00%
Address; 3090 W Anthem Way #109 / PMB 107 Anthem AZ 85086
Street City State Zp
Name: Percentage:
Address:
Street City State Zp
Please read A.R.S. § 4-203.02 and R19-1-205 Special event license rules and Requirements.
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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.

=> ATTACH DIAGRAM @&

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.

Declaration:
|, (Print Name) _ Edward John Salem Jr , declare under penalty of perjury that | am

authorized to submit this application. | have read the contents and to the best of my knowledge believe all statements

made on this application to be true, correct, and complete. Hs ;
Signature: (Ci GFA S47,

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:
e Overview of the location
e The event area clearly outlined with black marker
e Where alcohol will be served/stored
e All entrances and exits
e Where security will be positioned
e Square footage of event area
e Show North, East, South, West

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Individuals requiring ADA accommodations please call (602)542-2999

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