Extracted text (via ocr_local)
7686 characters
Arizona Department of Liquor Licenses and Control DLLC USE ONLY
https://www.azliquor.gov Job #:
(602) 542-5141 Date Accepted:
tc:
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 anunlicensed premises, it MUST be approved and signed by the Local Governing
Body Before submitting to the Arizona Department of Liquor.
LOCAL GOVERNING BODY
Date Received:
On behalf of
1 approvat 0 pisappROvaAt
Government Official Title
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?
LClves [No (if no skip to section 3)
If yes, MIUST attach a letter of explanation/permission/suspension from the licensed location and choose ONE option below.
Name of Licensed Location. Liquor License Number
O
O
O
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.
10/28/2025 Page 1 of 4
Individt inte ranuiina ANA aecaramadatinne Nance call [ANVO16AI-0000
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.
Salem Edward John, Jr.
Last
1. Applicant:
2. Applicant’s mailing address
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 (5S) years?
Llves (if yes, attach letter of explanation) \“] No
SECTION 4
Anthem Rotary Foundation
1. Name of non-profit organization:
AP ORAOTES 1:26 OUCADNSS 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:
Anthem Days
4. Special Event Name:
SECTION 5
5, Event Location Name: Anthem Community Park
41703 N Gavilan Peak Pkwy, Phoenix, AZ 85086
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.
4 Number of Police 4 Number of Security Personnel [“]rencing [Y]earriers
Must explain security measures: There will be 4 Maricopa County Sheriffs deputies on patrol as
well as security personnel. 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 LJoftt-site (auction/wine/distilled spirits pull) Cisoth
2. How many special event days have already been issued to this organization during the current year? 0
10/28/2025 Page 2 of 4
IndiviAiinde racing ADA AccAmemarintinne nance ool (46649-9000
SECTION 7
Dates and Hours of Event - Days must be consecutive and may not exceed 10 days per year.
DAYS DATE DAY OF WEEK ee oo re
pay, 03/14/2026 Saturday 09:00AM 7:00 PM
pay? 03/15/2026 Sunday 09:00 AM 7:00 PM
DAY 3
DAY 4
DAY 5 RECEIVED
DAY 6 FEB 0 6 2026
™ CLERK BOARD OF SUPE VISORS
DAY 8
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 [VIno 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: Anthem Rotarian Foundation Percentage: 100%
Address: 3055 W Anthem Way #109 / PMB 107 Anthem AZ 85086
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.
10/28/2025 Page 3 of 4
Indiviciinle raniiiinga ADA aArcaAmmadatinne nlanca call (ANG 49-9000
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.
=> ATTACHDIAGRAM
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.
Signature: Lf EH. Shale
a=
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
10/28/2025 page 4 of 4
Individuals requiring ADA accommodations please call (602)542-2999
Special Event Dia
E: Show ne:
(esu1h) wu rund jouopppo
‘gram: (Show dimenstons, serving areas, and label type of enclosure
arest cross streets, highway, or road If location doesn't have an address.
| I of th
. tre walkpaths . - Nt
SPECIAL EVENT LICENSED PREMISES DIAGRAM
{This dlagram must be completed with this application)
and security positions)
e dark area Is Q1ms5 the white areas
INDICATES THE FENCED AREA WHERE ROTARY SPECIAL EVENT
WILL BE HELD,
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