Application For Growler Privileges With Series 12 Liquor License - Arizona Department Of Liquor Licenses And Control

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FOR DLLC USE ONLY
Issuance Fee: $225.00
Arizona Department of Liquor Licenses and Control
Issuance Date:
800 W Washington 5th Floor
Phoenix, AZ 85007-2934
CSR:
(602) 542-5141
APPLICATION FOR GROWLER PRIVILEGES
WITH SERIES 12 LIQUOR LICENSE
Applicant’s Name: (
Owner
Agent) _____________________________________________ License #: ________________________
Business Name: _______________________________________________________________________________________________________
Business Location: ____________________________________________________________________________________________________
Street Address
City
State
County
Zip Code
Mailing Address: ______________________________________________________________________________________________________
Street Address or P.O. Box
City
State
County
Zip Code
Business Phone Number: ___________________________________ Daytime Contact Number: _________________________________
Email Address: ________________________________________________________________________________________________________
Distance to nearest School: _____________________________________ Name of School: _____________________________________
(if less than (1) mile note footage)
Address: _____________________________________________
Distance to nearest Church: ____________________________________ Name of Church: _____________________________________
(if less than (1) mile note footage)
Address: _____________________________________________
Growler Permit as authorized by A.R.S. 4-205.02.H
I
______________________________________________________________, attest that I am the OWNER/AGENT filing this
(Print Name),
form, and I that I have read, and assume responsibility for compliance with,
A.R.S. §4-205.02.H A.R.S. §4-
A.R.S. §4-207.A.
244.32.C and verify all statements I have made on this document to be true, correct and complete. I understand that I am
responsible for the $225.00 issuance fee and the annual $150.00 renewal fee for these growler privileges. Growler privilege
renewal fees are due at the same time as the renewal for the “current restaurant license” and are not transferable.
: __________________________________________
________________________________
__________________
Signature
Title:
Date:
DLLC USE ONLY
l
_________________________________ Date: ____/____/____
Investigation Recommendation:
Approva
Disapproval by:
Director Signature required for Disapprovals:
_____________________________________________________
Date: ____/____/____
7/28 /2016
Page 1 of 1
Individuals requiring ADA accommodations please call (602)542-9027

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