Sampling Privileges Applicattion Series 9 Or 10 - Arizona Department Of Liquor Licenses And Control
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1DLLC USE ONLY
Issuance fee: $100.00
Arizona Department of Liquor Licenses and Control
Issuance Date:
800 W Washington 5th Floor
Liquor Store (series 9)
Phoenix, AZ 85007-2934
Beer and Wine Store (series 10)
CSR:
(602) 542-5141
SAMPLING PRIVILEGES APPLICATTION
SERIES 9 OR 10
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: _________________________________________________________________________________________________________
Series #10 Beer and Wine Bar Only:
I declare that my business qualifies as a
Premises is 5,000 square feet or larger
At least 75% of shelf space is dedicated to beer and wine
A.R.S. §4-206.01(J) Bar, Beer and Wine Bar or Liquor Store licenses; number permitted; fee; sampling privileges
I
_______________________________________________, hereby declare that I am the OWNER/AGENT filing this form,
(Signature),
that I have read
and verify all statements made on this document to be true, correct, and complete to the
A.R.S. §4-206.01
best of my knowledge. I understand there is a $100 issuance fee and the annual $60 renewal fee for these sampling
privileges. The sampling privilege renewal fees are due at the same time as the renewal for the current license number
identified on the first line of this application.
LOCAL GOVERNING BOARD
I, ________________________________________ ___________________________ recommend
APPROVAL
DISAPPROVAL
(Government Official Signature)
(Title)
on behalf of _________________________________________________ __________________________ ___________________
(City, Town, County)
Phone
Date
DLLC USE ONLY
l
_________________________________ Date: ____/____/____
Investigation Recommendation:
Approva
Disapproval by:
Director Signature required for Disapprovals:
_____________________________________________________
Date: ____/____/____
2/1/2018
Page 1 of 1
Individuals requiring ADA accommodations please call (602)542-9027
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