NORTHWEST VALLEY CONNECT_REDACTED.PDF

DLLC USE ONLY

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

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 ore Organization ee

Wey n,
{, Appiicant: Northwest-Valtley Cennect Karen Chownol(2—
2. Applicant’s mailing address

3. Applicants home/cell — |

4. Applicant's email addres:

Cily State Zip
Applicant's business phone: 623-282-9304

Northwest Valley Connect

SECTION 2 Name of Non-Profit Organization, Candidate or Political Party/Gov.:

SECTION 3 Non-Profit/IRS Tax Exempt Number: 46-4635030
SECTION 4 Event Location; 12755 W. Beardsley Rd, Sun City West, AZ 85375

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**

Event Start License End
Days Date Day of Week Time AM/PM Time AM/PM

10/23/2022 Sunday 10:30AM 3:00PM

DAY 1:

DAY 2:

DAY 3:

DAY 4: a

DAY 5:

DAY 6:

DAY 7: nN -<s
ayy
DAY 8: Lieu

DAY 9:

DAY10:

41912021 Paae 1 of 3

SECTION 6 What iype of security and contro! 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.)

ice 2
Number of Police
Explanation: LNere will be a beer and wine tent set up in the park. The

permiter of the park will be enclosed with fencing with an officer
at the entrance to check ID's. Wristbands will be place on patron's
21 years and older.

Number of Security Personnel {ZlFencing [barriers

SECTION 7 Will this event be held on a currently licensed premises and within the already approved premises?
ClYes[41 No if yes, Local Governing Body signature is not required.

Name of Business Ucense 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

[bispense and serve alll spirituous liquors under retailer’s license
[1bispense and serve all spirituous liquors under special event
split premise between special event and retail location

SECTION? What is the purpose of this event?

(on-site consumption [Off-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?
(Yes (21 No 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?

[1 Yes [#1 No ff 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?

yes [1 No if yes, please provide the Narne 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 ihe proceeds, MUST EQUAL 100%.

Name: Northwest Valley Connect percentage:_100%
Address 2445 N. 99th Avenue — Peoria AZ 85345

Street City State
Name: Percentage:
Address:
Street City State Zip

41912021 Paae 2 of 3

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 spectal 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 focal 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

|, (Print Full Name) Kath ryn Chandler... 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 knowledge.

Applicant Signature:

GOVERNING BOARD

Date Received:

recommend LIAPPROVAL [1 DISAPPROVAL

(Government Official)

On behalf of

(City, Town, County) Signature

DLLC USE ONLY

TDIAPPROVAL LJ 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 attomey 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. A state employee may nof 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 abrogaie the immunity provided by section 12-820.01 or 12-820,02.

4/9/2021 Paae 3 of 3

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