KIWANIS CLUB OF NEW RIVER_REDACTED.PDF

DLLC USE ONLY

SPECIAL EVENT LICENSE Tob #:

APPLICATION FEE $25.00 PER DAY

Date Accepted:

Arizona Dept. of Liquor Licenses and Control CSR:
800 W. Washington St. 5 Floor Phoenix, AZ 85007
(602) 542-5141

Type or Print with Black Ink
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;

O22 2426922

pplicant's business phone:

3. Applicants home/cell phon
4. Applicant's email address:

SECTION 2 Name of Non-Profit Organization, Candidate or Political party/Gov:&/ LLG
SECTION 3 Non-Profit/iRS Tax Exempt Number: 235 ~ 2Z9F4BZLO A
SECTION 4 Arizona Corporation Commission File #: If out of State please specify:

SECTION 5 Event Location Name: Mew Aver. &, wryS LAK
SECTION 6 Event Address: FS le og A 27? Ad Mar, B vey? ¥sDax7

SECTION 7 Dates and Hours of Event. Days must be consecutive but may not exceed 10 consecutive days.

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

Days Date Day of Week UPA Sis |
DAY 1: 929/22 OT Ym LL bm |
DAY 2: |
DAY 3: |
DAY 4: :
DAY 5:

DAY 6 RECEIVED
DAY 7: AUG-O- |
DAY 8: MARICOPs COUNTY

DAY 9: CLERK BOARD OF SUPERVISORS

DAYI0: Mou! Ar

7/21/2022 Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-2999 |

Amendment

DLLC USE ONLY

SPECIAL EVENT LICENSE

APPLICATION FEE $25.00 PER DAY

Date Accepted:

Arizona Dept. of Liquor Licenses and Control
800 W. Washington St. 5" Floor Phoenix, AZ 85007
(602) 542-5141

Type or Print with Black Ink
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;
3. Applicants home/cell phon

4. Applicant's email address:

SECTION 2 Name of Non-Profit Organization, Candidate or Political party/Gove¥Z LAYS LL y
SECTION 3 Non-Profit/IRS Tax Exempt Number: a 3 ~ 74 FBZ 9 f

SECTION 4 Arizona Corporation Commission File #020 Mee If out of State please specify:

SECTION 5 Event Location Name:__ Urs ice Ke ie GAN D> La ALK

SECTION 6 Event Address: FS bo 0B A 2? AL Arn L Viy? Ssny¥ /

SECTION 7 Dates and Hours of Event. Days must be consecutive but may not exceed 10 consecutive days.

“*SEPARATE APPLICATION FOR EAGH “NON-CONSECUTIVE” DAY**

Days Date Day of Week time AM/PM time AMW/Pm
DAY 1: Wey td [22 SA Yau S Pyy_ _ pi bel
DAY 2:

DAY 3: ee
DAY 4: ee
DAY 5:

DAY 6: ——
DAY 7: _
DAY 8:

DAY 9: —____ ee
DAY 10: __ ee

7/21/2022 Page 1 of 3

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

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.)

Number of Police ‘ 3 Number of Security Personnel [Fencing JRbariers
Explanation: THEME. Afeé. Ste Ary. f: CHD COMACCL @ LATE < 5

41 At fludtE Sante

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

ClyYes [Kno If yes, Local Goveming 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
O isoense and serve alll spirituous liquors under retailer's license
ispense and serve all spirituous liquors under special event
plit premise between special event and retail location
SECTION 9 What is the purpose of this event?
(Abnsite consumption Lloff-site (auction/wine/disiilled spirits pull) [Both
SECTION 10

1. Has the gpplicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
Livesfidno 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?

Lves Divo 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?

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

5. List the name of the Individual or Organization that will Wy) B. revenues, MUST EQUAL 100%.

Name: 4, U/AAMNS [ kuih Vim Hen) whey? Percentage: WA LO
Address: [Ob 23x0F Men) faexe. AZ YS Y 2.

Street State
Name: Percentage:
Address:

Street City State Zip
7/23/2022 Page 2 of 3

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

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.

E> 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
to 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.

Declaration:

I, (Print Name) EB jp tHeD v1 as Vioxe_ declare under penalty of perjury that | am

authorized to submit this application. ! have read the contents of this applicatign, and to the bestéf my Knowledge

believe all statements made on this application to be true, correct and’tomplete.
& Mu e\
t

Signgtord
SN!

Date Received:

I, recommend LIAPPROVAL [1 DISAPPROVAL
(Government Official) (Title)

On behalf of , , ,
(City, Town, County) Signature Date Phone

CIAPPROVAL LC] 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.

7/21/2022 Page 3 of 3
Individuals requiring ADA accommodations please call (602}542-2999

ers

“x

3

Rage.

| cooing Sensing Area

ee

Fan eng Rope

Fencing —

aK
x
x *K

ARH

x

x Xx

x x
AK

ohms /preg |