ANTHEM ROTARY FOUNDATION_REDACTED.PDF

DLLC USE ONLY

Job #:
Arizona Department Liquor License and Control
800 W Washington St. 5!h Floor Date‘Accepted:
Phoenix, AZ 85007-2934 See
azliquor.gov .
602-542-5141 SELLS

SPECIAL EVENT LICENSE APPLICATION
FEE $25.00 PER DAY

A service fee of $25.00 will be charged for all dishonored checks (A.R.S § 44-6852
1-10 days consecutive days only, Cash, Checks or Money Orders Only

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:

2. Applicant's mailing address:
'Y

3. Applicants home/cell phone} licant's business

4. Applicant's email address:

SECTION 2 Name of Non-Profit Organization, Candidate or Political Party/Gov.: Anthem Qo Ma wd Fen dno

SECTION 3 Non-Profit/IRS Tax Exempt Number; 44 (-O9 3 O7le b/ Z6- 00640058
; p YI7o3 N Gavirn PEM Per
SECTION 4 Event Location: Duthen Comme ny Aud. Pirecniuc, Az

SECTION § Dates and Hours of Event. Days must be consecutive but may not exceed 10 consecutive days.
See A.R.S. § 4-244(15) and (17) for legal hours of service.

**SEPARATE APPLICATION FOR EACH “NON-CONSEGUTIVE” DAY**

Event Start License End
Time AM/PM Time AM/PM

DAY 1: _Ocr, JD D071. SATUAPAY 10 Am 4 PM,
DAY 2: Oct 23, WL Svsenmy joam 4PM

DAY 3:

Days Date Day of Week

DAY 4:

DAY 5:

DAY 6:

DAY 7:

DAY 8:

DAY 9:

DAY 10:

4/9/2021 Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-9027

SECTION 6 What lype 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.)

1
ph Number of Police !O Number of Security Personnel a Olearriers

Explanation: seve iS & EemCe Around +e area Which is PAT wed
by Seemmry pevsomnel

SECTION 7 Will this event be held on a currently licensed premises and within the already approved premises?

Dyes LANo If yes, Local Governing Body signature is not required.

Name of Business License Number Phone (Include Area Code)

SECTION 8 Howis this special event going to conduct all dispensing, serving, and selling of spirituous liquors? Please read
R-19-318 for explanation and check one of the following boxes,

ClPlace license in non-use

Dodispense and serve all spirituous liquors under retailer's license
Ospense and serve alll spirituous liquors under special event
Usplit premise between special event and retail location

SECTION 2 What is the purpose of this event?
ents consumption LOff-site (auction/wine/distilled spirits pull) [Both
SECTION 10

1. Has the appticant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
Oyes jo If yes, attach 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 Licensed Contractor?

Oyes Gao If yes, please provide the Name of the Licensed Contractor:

4. |s the organization using the services of a series 6, 7, 11, or 12 licensee to manage the sale or service of alcohol?

CyYes ino if yes, please provide the Name of Licensee: License #:

5. The applying non-profit organization must receive 25% of the gross revenues of the total liquor sales. List the names
of the individuals or organizations who will receive the rest of the proceeds, MUST EQUAL 100%.

Name: Prt ern le =—— Go JN DATIEN Percentage: / Oo
Address: BESS W Ayu Wry #109 Pubio7 Anthem, A& &&b

Street City State Zip
Name: Percentage:
Address:

Street City State Zip
4/9/2021 Page 2 of 3

Individuals requiring ADA accommodations please call (602)542-9027

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.

L

SECTION 11 License premises diagram. The licensed premises for your special event is the area in which you are
authorized fo 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.

a — — — = — —
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
fo the Department of Liquor Licenses and Control. 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.

SIGNATURE

a es a ST Seen Se Sana — —=

|, (Print Full Name) Solna Cate hereby swear under penally of perjury and in compliance
with A.R.S, § 4-210(A)(2) and (3) that | have read and understand the foregoing and verify that the rmation and
statements that | have made herein are true and correct to the best of my knowle

Applicant Signature

GOVERNING BOARD

Date Received:
1]

\, recommend LIAPPROVAL CI DISAPPROVAL

(Government Official) (Title)
|
On behalf of ‘ .
(City, Town, County) Signature Date Phone

, DLLC USE ONLY
CIAPPROVAL CL] DISAPPROVAL BY: DATE:
[— _— _ — — ———————————ee — —

A.R.S. § 41-1030. Invalidity of rules not made according to thls 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 ona 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 toa 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.

4/9/2021 Page 3 of 3
Individuals requiring ADA accommodations please call (602)542-9027

SPECIAL EVENT LICENSED PREMISES DIAGRAM
{This diagrarn musi be completed with this application)

Special Event Diagram: (Show dimensions, serving areas, and label type of enclosure and security positions)
TE: Show nearest cross streeis, highway, or road if location doesn't have an address.

pil of tne dark area |3 G1as5

Qinss The white areas

‘" INDICATES THE FENCED AREA WHERE ROTARY SPECIAL EVENT

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