ANTHEM ROTARY FOUNDATION_REDACTED.PDF

DLLC USE ONLY

Job #:
Arizona Department Liquor License and Control
800 W Washington St. 5' Floor Date Accepted:
Phoenix, AZ 85007-2934 a
azliquor.gov ,
602-542-5141 aS Le

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.

John Sacem

1. Applicant:

2. Applicant's mailing address:

3. Applicants home/cell phone: Applicant's business phone:

4. Applicant's email address:

mivilaa the

SECTION 2 Name of Non-Profit Organization, Candidate or Political Party/Gov.: hy hem { (Tk Ul Ul Ou

j

SECTION 3 Non-Profit/IRS Tax Exempt Ruribert | UY 0 Waen| db- U Of ; (C YOO .

P a) i; 7 = 7 ita)
SECTION 4 Event Location NO yttCh ) (fp Ct 10, Or) LU). ROSE LANDON UT IC, f I LIK
SECTION 5 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-CONSECUTIVE” DAY**

Days Date Day of Week nine AM/EM rea
DAY 1: lof7 Jas mw DAY 5:00 Pa 10:00 Pm"
DAY 2: lofy Jas SAV dort) 490 ON J/0: 00 F™
DAY 3: lola /ax Syn DAY Abou! 6PM

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

Amend meat -Seehon
Event adds

DLLC USE ONLY
Job #:
Arizona Department Liquor License and Control
800 W Washington St. 5!" Floor Date Accepted:
Phoenix, AZ 85007-2934 oe
azliquor.gov °
602-542-5141 Hcense #:

SPECIAL EVENT LICENSE APPLICATION
FEE $25.00 PER DAY

Aservice 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: ohn SA LEM

2. Applicant's mailing address:

3. Applicants home/cell phone: Applicant's business phone:

4. Applicant's email address:

SECTION 2 Name of Non-Profit Organization, Candidate or Political Party/Gov.: them foto Pury iH Any

SECTION 3 Non-Profi/RS Tax Exempt Number: 4 10%30L | &6-00b4O05S6 ;
2 7 n aA , TA r

SECTION 4 Event Locationt Kose (put oh (parks AG, lor ) L | . caay in (i ck, tt Yen IK AL

ST. LOSE PHLPPINE DUCHESNE CATHoLIe CHR 2925 W. Kost GaNqen Lie, ANTHEM, At BSOBL

SECTION 5 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-CONSECUTIVE” DAY**

DAY 1: lof-7 Jas. ori DA 5200 FM 1Q/0a FN
DAY 2: lofy/ar SAT oY 4io0 bul /0: 02 FM"
DAY 3: lo/9 />x SUNDAY Noord 6PM

DAY 4:

DAY 5:

DAY 6:

DAY 7:

DAY 8:

DAY 9:

DAY10:

4/9/2021 Page 1of3

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

SECTION 6 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.)

i R \
= Number of Police Number of Security Personnel [Fencing DAbaniers

Explanation: LyeQ ill lng SCOWE od bs { fe ACH a 4 g, Nn \AY C OMA COU muy
She a s OthceiS

SECTION 7 Will this event be held on a currently licensed premises and within the already approved premises?
Ove No If yes, Local Governing Body signature is not required.

Name of Business License Number Phone (Include Area Code)

SECTION 8 How is 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.

(Place license in non-use

Libispense and serve all spirituous liquors under retailer's license
Nlbispense 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?

\dlonssite consumption [CIOff-site (auction/wine/distilled spirits pull) [Both

SECTION 10

1. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
OYes BA No If yes, attach explanation.
Bs

2. How many special event days have been issued to this organization during the calendar year? ~
3. ls the Organization using the services of a Licensed Contractor?

C1 Yes1No If yes, please provide the Name of the Licensed 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?

D1 YesW No 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: Et re AN\ Kf PION Faw U de tH Percentage: loo VA
Address: vi Sess Ww Aedheon Way ra PMB jo7 Ont Ad 50 86

Street State
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.

SECTION 11 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 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

1, (Print Full Name) So hr SA Lew hereby swear under penalty 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 information and
statements that | have made herein are true and correct to the best of my encraineee

Applicant Signature:

GOVERNING BOARD

_=
Date Received: |

, recommend LIAPPROVAL LI DISAPPROVAL
(Government Official) (Title)

On behalf of

(City, Town, County) Signature Date Phone

DLLC USE ONLY

CIAPPROVAL LI DISAPPROVAL BY:

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. Astate 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

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