FOR DLLC USE ONLY
Event Date(s):
Arizona Department of Liquor Licenses and Control
Event time start/end:
800 W Washington 5th Floor
Phoenix, AZ 85007-2934
CSR:
(602) 542-5141
License:
APPLICATION FOR SPECIAL EVENT LICENSE
Fee= $25.00 per day for 1-10 days (consecutive)
Cash Checks or Money Orders Only
A service fee of $25.00 will be charged for all dishonored checks (A.R.S § 44-6852)
IMPORTANT INFORMATION: This document must be fully completed or it will be returned.
The Department of Liquor Licenses and Control must receive this application ten (10) business days prior to the event. If the special
event will be held at a location without a permanent liquor license or if the event will be on any portion of a location that is not covered
by the existing liquor license, this application must be approved by the local government before submission to the Department of
Liquor Licenses and Control (see Section 12).
SECTION 1
Name of Organization: ________________________________________________________________________________________
Name of Licensed Contractor only (if any): ________________________________________________________________
SECTION 2
Non-Profit/IRS Tax Exempt Number: _____________________________________________________________________________
SECTION 3 Event Location: ___________________________________________________________________________________________
Event Address: ____________________________________________________________________________________________
SECTION 4
Applicant must be a member of the qualifying organization and authorized by an Officer, Director, or Chairperson
of the Organization.
___________________________________________________________________ ________________________
1. Applicant:
Last
First
Middle
Date of Birth
_____________________________________________________________________________
2. Applicant’s mailing address:
Street
City
State
Zip
3. Applicant's home/cell phone: (____) __________________________ Applicant’s business phone: (____) _____________________
4. Applicant's email address: ___________________________________________________________________________________________
I,
________________________________________________
declare that I am the APPLICANT filing this application
(Print Full Name)
as listed above. I have read the application and the contents and all statements are true, correct and complete.
X ___________________________________ ___________________________________ _______________ ___________________
Signature
Title/ Position
Date
Phone Number
The foregoing instrument was acknowledged before me this
_______________ ____________________________ _______________
Day
Month
Year
State __________________County of ________________________
___________________
__________________________________________________________
My Commission Expires on:
Date
Signature of Notary Public
9/12/2017
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Individuals requiring ADA accommodations call (602)542-2999