RISEN SAVIOR LUTHERAN CHURCH_REDACTED.PDF

CSR:
Amount:

SPECIAL EVENT LICENSE
APPLICATION FEE $25.00 PER DAY

DLLC USE ONLY

Job #:

Date Accepted:

CSR:

Arizona Department of Liquor Licenses and Control
800 W. Washington St. 5" Floor Phoenix, AZ 85007
(602) 542-5141
Application MUST be submitted to the Department of Liquor 10 days prior to the event.

license #:

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: Mello Sus ar

(Must be an Officer/Member of the Ni
2, Applicant's mailing address:

3. Applicants home/cell phone: Applicant's business phone: 45

4. Applicant's email address:

ovenmberfest ,
6. Name of Non-Profit Organization, Candidate or Political rary/cov Sen Ay avior Lith COW CC h (ae robe
7, Non-Profit/IRS Tax Exempt Number: E/ N- &6 «O 7 ZU L H3 = OlSE/IES

8. Arizona Corporation Commission File #:0 75 ¢ 2 9Ulort out of State please specify:

(Attach letter of good standing)

9, Event Location name: Ai st) Gd Vioc Custheron Ch acah,
10. Event Address: $234 20 g, Alma Schooled , Sun lakes AZ FEZUS

Dates and Hours of Event - Days must be consecutive and may not exceed 10 consecutive days.

5. Special Event Name:

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

DAY I: [2 Jzo2y4 Sahucday 4:00) 00 2002 m
DAY 2:
DAY 3:
DAY 4:
DAY 5:
DAY 6:
DAY 7: RECEIVED
DAY 8: SEP 28 202:
DAY 9: MARICOPA COUNTY
RD OF SUPERVISORS —
DAY10:

2/6/2023 . Page 1 of3 .

(List type and number of police/security personnel and fype of fencing or control barriers, if applicable.)

20 numer of Police i Volu ntees Number of Security Personnel ClFencing Yeariess

Must explain security measures: i Polecsia nal bar dende cs ty mM on toc Conia pli

site - suite. akoho doesn't
leQve ever

SECTION 3 What is the purpose of this event?

fon-site consumption . CIO #-site (auction/wine/distilled spirits pull) Cboth

How is this special event going to conduct all dispensing, serving, and selling of spirituous liquors?
Check one of the following boxes. {R-19-318}

A) J Special Event being held on an unlicensed premises will require approval and signature by the Local Governing
Body on page 3. (If checked move to section 4)

B) [-] Will this event be held on a currently licensed premises and within the already approved and licensed area?
(Must attach a letter from the licensed premises with an explanation of the option checked below)

Name of Business License Number Phone (Include Area Code)

(Place license in non-use - Special Event Licensee selling all alcohol without retaiter involvement
Must attach letter from the location suspending license for duration of special event

[dispense and serve alll spirituous liquors under retailer's license — Business operates normally, minimum of 25% of gross
revenue from alcohol sales is donated fo licensee

Lbispense and serve alll spirituous liquors under special event - The special event licensee is in charge of selling alcohol that was
purchased or donated by the special event licensee. The refailers existing alcohol inventory must be separated from any alcoho!
used during the special event, Must attach letter from the location suspending license for duration of special event

[split premise between special event and retail location - Both the special event licensee and the retailer will conduct
sales of alcohol. (These sales will be done in separate areas. If alcohol is donated or purchased by the special event licensee
it must be in a separate area than the alcoho! that is dispensed by the licensed retailer.)

Clot sale only - Wine/Distilled Spirits Pull, Live or Sitent Auctions — Retailer will still be permitted to conduct all normal sale and
service of alcohol.

SECTION 4
1. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
oO vesl3{no If yes, attach letter of explanation.

2. How many special event days have been issued to this organization during the calendar year? oy,

3. Is the Organization using the services of a Special Event Contractor? (A licensee can utilize the services of a special event
contractor who may purchase and sell alcohol on behalf of the licensee. if no special event contractor is listed, the licensee is
responsible for the sales and service of alcohol. }

(71 Yes [XNo If yes, please provide the Name of the Special Event 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?
(Licensees who hold a series 6, 7, 11, or 12 license are automatically qualified to be the special event contractor)

ClyYes ti(ve if yes, please provide the Name of Licensee: License #:

5, List the name of the Individual or Organization that will receive revenues, MUST EQUAL 100 PERCENT.
Attach additional sheet if necessary.

2/6/2023 . _ Page 2 of 3 .

Nome: | (Sin avi oC Lutheran, (' h croh Percentage: /D@bee Seen Ly
Address:  23G1Y SS Alma Goheo| Ref Chendlec AZ SS AUS

Street City State lip
Name: Percentage:
Address:

Street Clty State 2p

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 5 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.

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 governing body before submitting
to the Department of Liquor Licenses and Control. Please contact the local governing board for additional information.

APPLICANT SIGNATURE

Declaration:

|, (Print Name} __s USA. a) Mel) Ile , declare under penalty of perjury that | am
authorized to submit this application. | have read the Oomlons of this application, and to the best of my knowledge
believe all statements made on this application to be true, correct an

LOCAL GOVERNING BODY

Date Received:

I, recommend CIAPPROVAL [1] DISAPPROVAL
(Government Official) (Title)

On behalf of

(City, Town, County) Signature Date Phone

The local governing body (city, town or municipality where the fair/festival will fake place) may require additional
applications to be completed and submitted. Please check with local government as fo how far in advance they require
these applications fo be submitted, Additional licensing fees may also be required before approval may be granted.

AZDLLC USE ONLY

CIAPPROVAL C] DISAPPROVAL BY: DATE:

2/6/2023 ; . Page 3 of 3

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