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Application For Temporary Expansion Of Licensed Premises - City Of Independence License Division Page 2

LICENSE DIVISION - CITY OF INDEPENDENCE, MISSOURI

111 East Maple, Independence, Missouri 64050

(816) 325-7079

APPLICATION FOR TEMPORARY EXPANSION OF LICENSED PREMISES

Date

The undersigned (individual owner) (partner) (Managing Officer) hereby makes application for a Temporary

Expansion of Licensed Premises.

Name of Owner/Partner/Managing Officer:

Establishment Applying for Temporary Expansion:

Independence Business Address:

Date(s) and time of temporary expansion:

Purpose of temporary expansion event:

Total dimensions of proposed expansion area:

If expansion is to be in a parking lot or open area, give brief description of type of fencing to be used and the

method to be used to control ingress and egress into the expanded area:

I, (please print)

of lawful age, and

duly sworn upon my oath, swear that the answers and information given in this application are true and complete to

the best of my knowledge and belief.

Owner/Partner/Managing Officer

Subscribed and sworn to before me this

day of

, 20

My Commission Expires:

Notary Public

Application For Temporary Expansion Of Licensed Premises - City Of Independence License Division Page 2