Application For Special Event License - Arizona Department Of Liquor Licenses And Control Page 2
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5he Officer, Director, or Chairperson of the organization
SECTION 5 Regarding
the application for a special event permit:
T
certifies that the Organization meets the criteria in A.R.S. § 4-203.02(E) as indicated by checking one of the
boxes below.
(1)
The Organization is a political party or a campaign committee supporting a candidate for public office. Please
indicate the name of the candidate that the Organization supports, the office that the candidate seeks, and the
month and year that the candidate would first fill the office if successful.
Candidate: __________________________________________________________________________________________________
Name
Office
Month/Year
(2)
The Organization is a non-profit entity organized in Arizona, or pursuant to the laws of another state that is eligible
for designation under Section 501(C) of the internal revenue code of the United States. If the Organization is
please also INITIAL
applying under option (2) as a nonprofit entity,
in the spaces provided next to all following
statements to indicate that, to the best of the Organization’s knowledge, the following statements are correct.
To be initialed only by an Officer, Director, or Chairperson of the organization.
_____ The Organization has received a determination letter from the Internal Revenue Service (“IRS”) indicating that it
is eligible for designation as a nonprofit entity under Section 501(C), eligibility or will be eligible on all days that the
special event will occur, or has a pending application with the IRS for such treatment that has not been resolved
but that will retroactively cover all days that the special event will occur. (Please provide a copy of either the IRS
determination letter or the application [without attachments] with this application).
_____ The Organization is not aware of any action taken by the IRS to revoke, suspend, or otherwise eliminate their
Eligibility under 501(C), or if there is a pending application, the eligibility has not received any indication that
the IRS will deny its application and has a good faith basis formed upon a reasonable inquiry into IRS regulations,
guidelines and forms that are eligible under 501(C).
_____ The Organization understands that if there is a change in circumstances after completing this form that may
cause or has caused it to lose its eligibility under 501(C), whether before or after receiving an IRS determination
letter, that it has an affirmative duty to notify the Department of Liquor, which may take appropriate action
regarding the loss of eligibility.
To be completed only by an Officer, Director, or Chairperson of the organization.
I,
________________________________________________
declare that I am an Officer, Director, or Chairperson of
(Print Full Name)
the organization filing this application 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
SECTION 6
Will this event be held on a currently licensed premise and within the already approved premises?
Yes
No
(If yes, Local Governing Body Signature not required)
Name of Business
License Number
Phone (Include Area Code)
9/12/2017
Page 2 of 5
Individuals requiring ADA accommodations call (602)542-2999
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