ANTHEM ROTARY FOUNDATION_REDACTED.PDF

CSR:

Amount:
1 DLLC USE ONLY
Job #:
SPECIAL EVENT LICENSE ——
APPLICATION FEE $25.00 PER DAY ,
CSR:
Arizona Department of Liquor Licenses and Control
800 W. Washington St. 5" Floor Phoenix, AZ 85007 conse £-

(602) 542-5141
Application MUST be submitted to the Department of Liquor 10 days prior to the event.

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; Salem Edward John, Jr.
(Must be an Officer/Member of the No! Middle

| on 90 "
3. Applicants home/cell phone: Applicant's business phone: 623-900-1001

4. Applicant's email address
Charity Classic Dinner Event

5. Special Event Name:

6. Name of Non-Profit Organization, Candidate or Political Party/Gov.: Anthem Rotary Foundation

47-0930766 / 26-00640058

7. Non-Profit/IRS Tax Exempt Number:

8. Arizona Corporation Commission File #: 109477921 If out of State please specify:
(Aitach letter of good standing)

9. Event Location Name: Ironwood Country Club
10. Event Address: 41551 N Anthem Hills Dr, Phoenix, AZ 85086

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

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

Days Date Day of Week Bada ii ues aed
bavi: 11/07/2024 ~—Ss Thursday 3:00 PM 40:00 PM
DAY 2:
DAY 3:
DAY 4:
DAYS: RECEIVED __
DAY 6: AUG
DAY 7: -
DAY 8: CLERK BOARD OF SUPERVISORS
DAY 9:
DAY10:
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SECTION 2 What type of security and contro! measures will you fake fo prevent violations of liquor laws at this event?
(List type and number of police/security personnel and type of fencing or contro! bamlers, If applicable.)

2 Number of Police 2 Number of Security Personnel [Fencing Csarriers

Must explain security measures: Maricopa County Sheriffs and Security Personnel will be on site

patrolling the event.

SECTION 3 What is the purpose of this event?

On-site consumption (Coit-site (auction/wine/distilled spirits pull) Clboth

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) [4] Special Event being held on an ynileensed 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 currenily licensed premises and within the already approved and licensed area?
(Must aitach a letter from the licensed premises with an explanation of the option checked below)

Name of Business Ucense Number Phone (Include Area Code)

lace ticense in non-use - Special Event Licensee selling all alcoho! without retailer involvement
Must attach letter from the location suspending license for duration of special event

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

Cbispense 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 retailers existing alcohol inventory must be separated from any alcohol
used during the special event. Must attach letter from the location suspending license for duration of special event

Cspiit 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 alcohol that is dispensed by the licensed retailer.)

Loft sale onty - Wine/Distilled Spirits Pull, Live or Silent 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?

(1 Yes J No If yes, attach letter of explanation.

2. How many special event days have been issued to this organization during the calendar year? 3

3. 1s 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. }

(1 Yes H1No If yes, please provide the Name of the Special Event Contractor:

4, ls 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)

(1 Yes [4JNo 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.

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Anthem Rotary Foundation Percentage: 100%

Name:
Address: 3655 W Anthem Way, #109 / PMB 107, Phoenix, AZ 85086
Street City State ap
Name: Percentage:
Address:
Street City State Tp

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 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.

If the special event will be held at a Id at a location w without a permanent ithout a permanent liquor license or if the event will be on any portion ofal 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:

1, (Print Name) LDUHLD. Tbs SALEra F72. , declare under penalty of perjury that | am
authorized to submit this application. | have read the contents of this application, and to the best of my knowledge

believe all statements made on this application to be true, ttle (hes Lau

‘ Signature

LOCAL GOVERNING BODY

Date Received:

1, recommend LIAPPROVAL [1 DISAPPROVAL
(Government Official)

On behalf of

(City, Town, County)

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

AZDLLC USE ONLY

CIAPPROVAL C1 DISAPPROVAL BY:

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Edward John Salem Jr
Anthem Rotary Foundation
3655 W Anthem Way #109 PMB 107

Anthem, AZ 85086
August 1, 2024

Arizona Department of Liquor Licenses and Control
800 W Washington St, 5" Floor
Phoenix, AZ 85007

To whom it may concern,

With regard to section 3 of the Special Event License Applications, | am including the following
information:

For our upcoming “Autumn Fest in Anthem special event as well as both Charity Classic events, all
spirits and beverages are supplied to the Anthem Rotary Foundation by a wholesale distributor. The
company is Crescent Crown Distributing, 1640 W Broadway Rd, Mesa, AZ 85202

Thank you. Sincerely,

dward John Salem Jr.