Application For Liquor License Type Or Print With Black Ink - Arizona Department Of Liquor Licenses And Control

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DLLC USE ONLY
License #
Arizona Department of Liquor Licenses and Control
Date Accepted:
800 W Washington 5th Floor
Phoenix, AZ 85007-2934
CSR:
(602) 542-5141
Application for Liquor License
Type or Print with Black Ink
APPLICATION FEE AND INTERIM PERMIT FEES (IF APPLICABLE) ARE NOT REFUNDABLE
A service fee of $25 will be charged for all dishonored checks (A.R.S. § 44-6852)
Type of License
Type of Ownership
SECTION 1
SECTION 2
J.T.W.R.O.S.
Interim Permit
Individual
New License
Partnership
Person Transfer (series 6, 7 and 9)
Corporation
Location Transfer (series 6, 7 and 9)
Limited Liability Co
Probate/ Will Assignment/ Divorce Decree (No Fees)
Club
Seasonal
Government
Trust
Tribe
Other (Explain) _________________________
SECTION 3 Type of Privilege
Add Sampling Privilege for Series 9 and 10 only (Complete Sampling Privilege application)
A.R.S.§4-206.01(G), (H), (I) & (L)
Add Growler privileges
(restaurant, series 12, license only. 300-foot restriction applies)
A.R.S.§4-207(A) & (B)
LICENSE
1.Type of License (Series of license): ______________________________
2.
#______________________________
SECTION 4 Applicants
1. Agent’s Name: ________________________________________________________________________________________________
Last
First
Middle
2. Individual/Owner Name: ______________________________________________________________________________________
(Ownership name for type of ownership checked in section 2)
3. Business Name (Doing Business As-DBA): _______________________________________________________________________
4. Business Location Address: ____________________________________________________________________________________
(Do not use PO Box)
Street
City
State
Zip Code
County
5. Mailing Address: ______________________________________________________________________________________________
(All correspondence will be mailed to this address)
Street
City
State
Zip Code
6. Business Phone: ___________________________________ Daytime Contact Phone: ___________________________________
7. Email Address: ________________________________________________________________________________________________
8. Is the Business located within the incorporated limits of the above city or town?
Yes
No
If you checked no, in what City, Town, County or Tribal/Indian Community is this business located? ___________________
9. Total Price paid for Series 6 Bar, Series 7 Beer & Wine Bar or Series 9 Liquor Store (license only) $ __________________________
Department Use Only
____________
____________
____________
____________
_____________
Fees:
$
Total of All Fees
Application
Interim Permit
Site Inspection
Finger Prints
1/11/2018
page 1 of 6
Individuals requiring ADA accommodations please call (602)542-2999

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