ANTHEM ROTARY FOUNDATION. REDACTED .PDF

I CSR: 
Amount: 
SPECIAL EVENT LICENSE 
APPLICATION FEE $25.00 PER DAY 
Arizona Department of Liquor Licenses and Control 
800 W. Washjngton St. 5th Floor Phoenix, AZ 85007 
(602) 542-5141 
DLLC USE ONLY 
Job#: 
Date Accepted: 
CSR: 
License#: 
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 Otticer/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: 623-900-1001 
4. Applicant's email address:
 
5. special Event Name: Autumn Fest of Anthem 
6. Name of Non-Profit Organization, Candidate or Political Party/Gov.: Anthem Rotary Foundation 
7. Non-Profit/IRS Tax Exempt Number: 4 7-0930766 / 26-00640058 
8. Arizona Corporation Commission File #: 1094 77921 If out of State please specify: ______ _ 
(Attach letter of good standing) 
9. Event Location Name: Anthem Community Park 
10. Event Address: 41703 N Gavilan Peak Pkwy, Phoenix, AZ 85086 
2/6/2023 
Dates and Hours of Event - Days must be consecutive and may not exceed 10 consecutive days. 
Days 
DAY l : 
DAY2: 
DAY3: 
DAY 4: 
DAY 5: 
DAY 6: 
DAY 7: 
DAY8: 
DAY9: 
DAYlO: 
**SEPARATE APPLICATION FOR EACH "NON-CONSECUTIVE" DAY** 
Date 
10/14/2023 
10/15/2023 
Day of Week 
Saturday 
Sunday 
Page 1 of 3 
Event Start 
Time AM/PM 
09:00 AM 
09:00 AM 
License End 
Time AM/PM 
06:00 PM 
06:00 PM 
REGEIVE 
..... D-1-------
JUL 3 12023 
MARICOPA COUNTY 
Ci.ERK BOARD OF SUPERVISORS 
Individuals requiring ADA accommodations please call (602)542-2999

=~"'-""'~= What type of security and control measures will you take to prevent violations of liquor laws at this event? 
(Ust type and number of 
and 
or control barriers, If 1:1Cl111ic1:1ble. 
4 
of Police _4 ______ Number of Security Personnel 
IZ:!Fencing 
0Barriers 
Must explain security measures: Maricopa County Sheriffs Deputies will be at both entrances to the park 
event. 
will be 
the area of the event. 
SECTION 3 What is the purpose of this event? 
[aon-site consumption 
00ff-stte (auction/wine/distllled spirits pull) 
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} 
08oth 
A) 0 Special Event being held on an 
premises will require approval and signature by the Local Governing 
Body on page 3. (If checked move to section 4} 
B) D 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 
l.k:ense Number 
0Ptace license in non-use - Special Event Licensee selling all alcohol without retailer involvement 
Must attach lefter from the location suspending license for duration of special event 
Phone (Include Area Code) 
0Dispense 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 
ODispense and serve all 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 Hcense for duration of special event 
Osplit 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.} 
Doff Sole only • Wine/Dlsfllled Spirits Pull, Uve or Silent Auctions - Retailer will still be permitted to conduct all normal sole and 
service of alcohol. 
SECTION4 
l. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years? 
D Yes 0 No If yes, attach letter of explanation. 
2. How many special event days have been issued to this organization during the calendar year? _6 ______ _ 
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. ) 
D Yes 0 No If yes. please provide the Name of the Special Event 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? 
(Licensees who hold a series 6, 7, 11, or 12 license are automatically qualified to be the special event contractor) 
0 Yes 0 No 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 
Page2 of3 
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Name: Anthem Rotary Foundation 
Percentage: 100% 
Address:
Street 
City 
Stote 
Zip 
Name: 
Percentage: 
Address: 
Street 
City 
State 
Zip 
Please read A.R.S. § 4-203.02 Special event license: rules and Rl 9-1-205 Requirements for a Special Event License. 
ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY. 
NO ALCOHOLIC BEVERAGES SHALL LEAVE A SPECIAL EVENT UNLESS THEY ARE IN AUCJION WINE OR DISI!LlliQ SPIRITS PULL 
SEALEQ CONTAINERS OR THE SPECIAL EVENT LICENSE 1$ STACkEQ WITH WINE /CRAFT QISTILLEBY FESTIVAL LICENSE 
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. 
II 
> ATIACH DIAGRAM < !1 II 
If the special event w!ll be held at a location without a permanent liquor ncense or If the event will be on any portion of a locaHon 
that Is not covered by the exlsHng liquor license, this applleaHon 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 addltlonal Information. 
APPLICANT SIGNATURE 
Declaration; 
t. (Print Name) Edward John Salem Jr 
, declare under penalty of perjury that I am 
authorized to submit this application. I have read the contents of this application, and to the best of my knowledge 
believe all stafemen!s made on this application to be true,~ 
~2 
.. 
Signature 
LOCAL GOVERNING BODY 
Date Received: _______ _ 
!, ____________________ ____ recommend 0APPROVAL DDISAPPROVAL 
(Government Olllc:lal) 
(lllle) 
On behalf of ___________ ----------- ____ __, _______ _ 
(City, Town, County) 
Signature 
Date 
Phone 
The local governing body (city, town or munlclpafffy where the fair/festival wlll take place) may require addltlonal 
applications to be completed and submffted. Please check with local government as to how far In advance they require 
these applications to be submffted. Additional licensing fees may also be required before approval may be granted. 
AZDLLC USE ONLY 
I 
DAPPROVAL a 01SAPrROvAL sv: _ ____________ oAre: _______ _ 
2/6/2023 
Page 3 of3 
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SPECIAL EVENT LICENSED PREMISES DIAGRAM 
(This diagram must be completed with this application) 
·:1 
. 
Special Event Diagram: (Show dimensions, serving areas, and label type of enclosure and security positions) 
NOTE: Show nearest cross streets, highway, or road If locatlon doesn't have an address. 
All 6t -r"~ dO?KO:Yta.1S -~rcijj-ff)i uik~Drrns 
Ci ri wet 1 k fC~i115 ~ · . 
tNDICAl'ES THE FENCED AREA WHERE ROTARY SPECIAL EVENT Nt 
WILL BE HELD, 
. 
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Edward John Salem Jr 
Anthem Rotary Foundation 
 
 
July 24, 2023 
Arizona Department of Liquor Licenses and Control 
800 W Washington St, 5th Floor 
Phoenix, AZ 85007 
To whom it may concern, 
With regard to section 3 of the Special Event License Application, I am including the following 
information: 
For our upcoming "Autumn Fest in Anthem special event, 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 
Please contact me at
 
if you have any questions. 
Thank you. Sincerely, 
k~~c?-
Edward John Salem Jr.