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 aR:
azliquor.gov ,
602-542-5141 Hcense #:

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: Creencte in , Jt Ly , /v\ .

City 7 Stale
Applicant's business phone: (3 “Vv

3. Applicants home/cell phon

4. Applicant's email address;
SECTION 2 Name of Non-Profit Organization, Candidate or Political pary/Govst thei Ron ud) fov nd ah 6)
SECTION 3 Non-Profit/IRS Tax Exempt Number: LP 0% 30"\ob [ JL ~ 00100 58

SECTION 4 Event Location: Hin Mt (or nw ty fale

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 TOG ee on
pay July3,2022 Suny —-_p.00 PM (0.00 f/)
DAY 2: E
DAY 3:
DAY 4:
RECEIVED OF
ayy: MAY 0§ 2022
DAY 8: CLERK BOARD CE SUPER VISORS
DAY ?:
DAY10:

4/9/2021 Page 1 of 3

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

IN Ep nent
Lo Gh Add regs

; DULG USE ONLY
j Job #:
Adzona Depart Liquor License and Control
800 W Washington Si. 5! Floor j Bale. Ag eepier

Phoenix, AZ 85007-2934

> charged for alld
ulive days only, Cash, ¢

é S(A.RS § 44-6
ecks or Money Orders Only

ser of a qua
or, oF Chai

fying nonprofit organization, political party, or Government entity and
rson of the Organization.

icant's mailing ¢

shone:

SOIR

2 ot XA 7

> 10 consect utive aays,

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

Days Bate De {Week Event Start License End
“ays mae SEE Time AM/PM Time AM/PM
i «A AnAY A Py PLA

Individuals requiring ADA Hions please carl (6¢

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 0 Number of Security i \Brencing \ pears
Explanation: [exe (S 0 Le ence QuDUriD the. QUEL whic! VAS
also satiolie by Security peizorine|

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

Lbispense and serve alll spirituous liquors under retailer's license
bispense and serve alll spirituous liquors under special event

Lisplit premise between special event and retail location

SECTION 9 What is the purpose of this event?

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

SECTION 10

1. Has Re goplcant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
Yes NINo If yes, attach explanation. L

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?

C1 Yes ©J No 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 Yes®) 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%.

voreft hear Lofty Foundaehion rercenoge: [00°/-
Address! H (20% N Club fone Dr fnthem AZ S50bb

Street Clty State
Name: Percentage:
Address:

Street Clty 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.

AL Li L E E E L NE OR DISTILLED SPIRIT:
LL SE TAINE R THE SPE L EVENT LICENSE E /CRAFT DISTILLERY FESTIV,
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 @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
to the Department of Liquor Licenses and Control. Please contact fhe 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

f Lp neste;

I, (Print Full wamen \()-ErOny (n Gre ONSHErereby 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 Sia.

e. -
Applicant Signat Mia hocntti

GOVERNING BOARD

Date Received:

|
I, recommend DIAPPROVAL [DISAPPROVAL
(Government Official) (Title)
On behalf of , , .
(City, Town, County) Signature Date Phone
DLLC USE ONLY

CIAPPROVAL CI 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

SECHON 72 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. The following space is to be used to

prepare a diagram of your special event licensed premises, Please show dimensions, serving areas,
other control measures and security position.

fencing, barricades, or

Location: Park Stadium Softball Fieidl. N T
C Red\ine depicts perimeter fencin

g 6’ high (standard softball field).
rea depicts entry/exit points — to be

guarded by Maricopa County Sheriff's
ice deputies and private security guards.
epresents serving locations.

Mempniol Dnve-

t

3/1/2016 rogesoratf iro (ynmun Ly fyrk—

Individuals requiring ADA cecommodations call (602)542-9027.