Application For Licensure To Hold Closed Circuit Telecasts Form - 1999
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1
2
3BUSINESS AND PROFESSIONS DIVISION
PROFESSIONAL ATHLETICS
P.O. BOX 9649
OLYMPIA, WA 98507-9649
PHONE: (360) 753-3713
FAX: (360) 753-3747
APPLICATION RECORD
Office Receipt
Date Received
APPLICATION FOR LICENSURE TO HOLD
Date Approved
CLOSED CIRCUIT TELECASTS
Date Expires
All answers must be printed or typewritten
Bond
Click Here to Start, Then Tab From Field to Field
Date License Certificate Sent
Promoter License No.
,
CITY OR TOWN
DATE
The undersigned, having submitted the necessary bond of $
hereby makes application to conduct
Closed Circuit Telecasts in accordance with RCW 67.08, and any amendments thereto, and subject always to the Rules and
Regulations of the Washington State Department of Licensing, Professional Athletics (WAC 36-12).
It is agreed that this License may be suspended or revoked for cause by said Department, and that it is not transferable
to any other party or parties nor to any other location.
Legal Name of Person, Club, Corporation or Association
Phone (
)
Street
City
State
Zip
Premises where event will be held: Name
Phone (
)
Address
Person representing licensee at event: Name
Phone (
)
Address
OFFICERS
President
Address
Vice-President
Address
Secretary
Address
Treasurer
Address
Registered Agent
Address
!
!
Incorporated?
Yes
No
Date of Incorporation
Date of filing certificate
Where filed
(ATTACH ARTICLES OF INCORPORATION IF APPLICABLE)
The Department of Licensing has a policy of providing equal access to its services. If
you need special accommodation, please call (360) 753-3713 or TTY (360) 586-2788.
PA-611-011 CC TV APP. (R/11/99)FM/W Page 1 of 3
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