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Armemded thio DLLC USE ONLY Job #: SPECIAL EVENT LICENSE | Date Accepted: APPLICATION FEE $25.00 PER DAY CSR: Arizona Department of Liquor Licenses and Control = license #: 800 W. Washington St. 5"" Floor Phoenix, AZ 85007 (602) 542-5141 Application MUST be submitted to the Department of Liquor 10 days prior to the event. SECTION 1 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: Voss Jessica L. 2. Applicant's mailing address: City State Zip 3. Applicants home/cell —_—_ Applicant's business phone: 6029351059 5. Special Event Name: /naugural EmpoweRanch Roundup 6. Name of Non-Profit Organization, Candidate or Political Party/Gov.: EmpoweRanch 82-2485216 7. Non-Profit/IRS Tax Exempt Number: 8. Arizona Corporation Commission File #: 21518051 If out of State please specify: (Attach letter of good standing) 9. Event Location Name: Amadio Ranch 10. Event Address: 4701 W Dobbins Rd, Laveen Village, AZ 85339 Dates and Hours of Event - Days must be consecutive and may not exceed 10 consecutive days. **SEPARATE APPLICATION FOR EACH “NON-CONSECUTIVE” DAY** Event Start License End Bays Pale Dovel Weck Time AM/PM Time AM/PM DAY 1: 01/21/2023 Saturday 3:00 pm 8:00 pm DAY 2: DAY 3: DAY 4: DAY 5: DAY 6: DAY 7: DAY 8: DAY 9: DAY10: 10/27/2022 Page 1 of 3 Individuals requiring ADA accommodations please call (602)542-2999 CSR: Amount: DLLC USE ONLY SPECIAL EVENT LICENSE ~ _ APPLICATION FEE $25.00 PER DAY aie Accepted: CSR: Arizona Department of Liquor Licenses and Control 800 W. Washington St. 5"" Floor Phoenix, AZ 85007 ticense (602) 542-5141 Application MUST be submitted to the Department of Liquor 10 days prior to the event. SECTION 1 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: Voss Jessica L. Last First Middle 2. Applicant's mailing address: “ise 2 20—COCOily— i ( ttst~—‘“‘(‘COCSCSC*;*C*CSKSC( et sti SS 3. Applicants home/cell phone: | (“otéeErrr Applicant's business phone: 6029351059 5. Special Event Name: /naugural EmpoweRanch Roundup 6. Name of Non-Profit Organization, Candidate or Political Party/Gov.: EmpoweRanch 7. Non-Profit/IRS Tax Exempt Number: 82-2485216 8. Arizona Corporation Commission File #: 21518051 If out of State please specify: ; (Attach letier of good standing) 9. Event Location Name: Amadio Ranch 10. Event Address: 4701 W Dobbins Rd, Laveen Village, AZ 85339 Dates and Hours of Event - Days must be consecutive and may not exceed 10 consecutive days. ** SEPARATE APPLICATION FOR EACH “NON-CONSECUTIVE” DAY** Event Start License End Days letelts Dayiotek Time AM/PM Time AM/PM DAY 1: 01/21/2023 Saturday 3:00 pm 8:00 pm DAY 2: DAY 3: DAY 4: DAY 5: DAY 6: +0 AON iV DAY 7: nlauvod ayo DAY 8: DAY 9: DAY10: 10/27/2022 Page 1 of 3 Individuals requiring ADA accommodations please call (602)542-2999 SECTION 2 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.) . . Event tickets are paid for and reserved in advance. ID is confirmed at check-in. The Must explain security measures: event is only for 21+. We will have at least two security personnel and will train our 15 volunteers Number of Police Number of Security Personnel [Fencing [Barriers in proactive risk management procedures concerning alcohol consumption on site. SECTION 3 What is the purpose of this event? Con-site consumption [ott-site (auction/wine/distilled spirits pull) Ypoth 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) A) Special Event being held on an unlicensed premises will require approval and signature by the Local Governing Bdy on page 3. (If checked move to section 4) B) LJ Will this event be held on a currently licensed premises and within the already approved and licensed area? (Must attach a leiter from the licensed premises with an explanation of the option checked below) Name of Business license Number Phone (Include Area Code) [Place license in non-use - Special Event Licensee selling all alcoho! without retailer involvement Must attach letter from the location suspending license for duration of special event Libispense and serve all spirituous liquors under retailer's license — Business operates normally, minimum of 25% of gross revenue from alcohol sales is donated to licensee Lbispense and serve alll 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 separated from any alcohol used during the special event. Must attach letter from the location suspending license for duration of special event Lbplit premise between special event and retail location - Both the special event licensee and the retailer will conduct sales of alcohol. (These sales will be done in separate areas. If alcohol is donated or purchased by the special event licensee it must be in a separate area than the alcoho! that is dispensed by the licensed retailer.) [o# sale only - Wine/Distilled Spirits Pull, Live or Silent Auctions — Retailer will still be permitted fo conduct all normal sale and service of alcohol. SECTION 4 1. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years? yes [YJ No If yes, attach letter of explanation. 2. How many special event days have been issued to this organization during the calendar year? 3. Is the Organization using the services of a Special Event Contractor? (A licensee can utilize the services of a special event contractor who may purchase and sell alcohol on behalf of the licensee. If no special event contractor is listed, the licensee is responsible for the sales and service of alcohol. } LC yYes[¥] No If yes, please provide the Name of the Special Event Contractor: 4, 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 the special event contractor) C1 Yes [INo if yes, please provide the Name of Licensee: License #: 10/27/2022 Page 2 of 3 Individuals requiring ADA accommodations please call (602)542-2999 5. List the name of the Individual or Organization that will receive revenues, MUST EQUAL 100 PERCENT. Attach additional sheet if necessary. Name: EmpoweRanch Percentage: 100 Address: 3104 E Camelback Rd #760, Phoenix, Arizona 85016 Street Cily State Zip Name: Percentage: Address: Street City State Zip Please read A.R.S. § 4-203.02 Special event license; rules and R19-1-205 Requirements for a Special Event License. ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY. SECTION 5 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 governing body before submitting to the Department of Liquor Licenses and Control. Please contact the local governing board for additional information. APPLICANT SIGNATURE Declaration: |, (Print Name) essica-Voss , declare under penalty of perjury that | am authorized to submit this application. | have read the contents of this application, and to the best of my knowledge believe all statements made on this application to be true, correct and complete. Gecacna. L. Ves Signature LOCAL GOVERNING BODY Date Received: I, recommend CIAPPROVAL [1 DISAPPROVAL (Government Official) (Title) On behalf of (City, Town, County) Signature AZDLLC USE ONLY DAPPROVAL C1 DISAPPROVAL _ BY: 10/27/2022 Page 3 of 3 Individuals requiring ADA accommodations please call (602)542-2999 J AA2L Quo a1q@L 19 dj AGL — 9 do. SalTAnOY aan 2 OP A Bie «site Oe he = ee Aq peyeorpul Suloue, “ = CXz a y 3 eeramig i J Y ) Ge d ) Y ysuesy @ Y Op o7s rt nar “ie »< = a