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DLLC USE ONLY Job #: SPECIAL EVENT LICENSE Date Accepted: APPLICATION FEE $25.00 PER DAY 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: Klose, Dana (Must be an Officer/Member of the Non Profit Entity) Last First Middle 2. Applicant's mailing address: Street City State Zip 3. Applicants home/cell phone: Applicant's business phone: 4. Applicant's email adres ln Vertigo Night Run 5. Special Event Name: 6. Name of Non-Profit Organization, Candidate or Political Party/Gov.: __One Love Arizona: Rescue, Advocacy & Sterilization 47-1365736 7. Non-Profit/IRS Tax Exempt Number: 8. Arizona Corporation Commission File #: 19399131 If out of State please specify: (Attach letter of good standing) 9. Event Location Name: White Tank Mountain Regional Park 20304 W. White Tank Mountain Rd. Waddell, AZ 85355 10. Event Address: Dates and Hours of Event - Days must be consecutive and may not exceed 10 consecutive days. **SEPARATE APPLICATION FOR EACH “NON-CONSECUTIVE” DAY* DAY 1: August 10 2024 Saturday 6:00pm 2:00am DAY 2: DAY 3: DAY 4: es si DAY 5: Ree * ve x CENED DAY 6: g ak - DAY 7: ms ¢ * — on “ous S DAY 8: ae ARIE oF SuPERN DAY 9: hd qLenKeo DAY10: 2/6/2023 Page 1 of 3 Individuals requiring ADA accommodations please call (602)542-2999 SECTION 2 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.) 1 Number of Police Number of Security Personnel bZlFencing Cibarriers . . ID check and wristbands to those 21 rs and older. Security patrol will remai Must explain security measures: and wristbands lo those years an older, security palro: ill remain al entrance/exit to beer garden for duration of event and will ensure no alcohol leaves the designated, fenced off area. SECTION 3 What is the purpose of this event? [ZlOn-site consumption (oft-site (auction/wine/distilled spirits pull) [Both 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) MZ] 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) C1 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) LPlace license 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 Lidispense and serve alll spirituous liquors under retailer's license — Business operates normally, minimum of 25% of gross revenue from alcohol sales is donated to licensee Lbispense and serve alll spirituous liquors under special event - The special event licensee is in charge of selling alcoho! that was purchased or donaied 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 Lisplit 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.) Llof Sale only - 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? Yes KZINo If yes, attach letter of explanation. 2. How many special event days have been issued to this organization during the calendar year? 3 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. ) WZ Yes CINo if yes, please provide the Name of the Special Event Contractor:Aravaipa Running, Noah Dougherty 4, Is 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) (Yes WINo 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 Individuals requiring ADA accommodations please call (602)542-2999 Name; One Love Arizona: Rescue, Advocacy & Sterilization _ percentage: 5 oc Street Cily State Zip Name: Aravaipa Running Percentage: 39 Address: 2401 S. 24th Street Phoenix Arizona 85034 Street City State Zip 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. — 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 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) Dana Klose , 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, correct and SAL Ze Z Signature LOCAL GOVERNING BODY Date Received: I, recommend LIAPPROVAL [1 DISAPPROVAL (Government Official) (Title) On behalf of (City, Town, County) Signature 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 LI DISAPPROVAL BY: 2/6/2023 Page 3 of 3 Individuals requiring ADA accommodations please call (602)542-2999