Application For Private Club Locked Front Door - Arizona Department Of Liquor Licenses And Control
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1
2Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Phoenix, AZ 85007-2934
(602) 542-5141
APPLICATION FOR PRIVATE CLUB LOCKED FRONT DOOR
Club Name: __________________________________________________________ Club License Number: ________________________
1.
2. Club/License Location: ______________________________________________________________________________________________
3. Agent’s Name: ______________________________________________________________________________________________________
4. Mailing Address: _____________________________________________________________________________________________________
5. Business Phone: ____________________ Daytime Contact Number: _____________________Club Phone: _____________________
6. Provide a complete explanation of the reasons for your request to lock your front door, including the security and safety
concerns. (use reverse side of this form and additional sheets in needed.)
7. Local law enforcement authority has reviewed this application. Comments, if any, by the local enforcement agency
may be made on the back of this form.
X _____________________________________________________________________________________________________________________
(Authorized Law Enforcement Signature)
(Title)
(Agency)
(Date)
8. When the premises is occupied, the Club hereby agrees to provide immediate access to law enforcement, fire fighters
and emergency medical personnel. We understand that permission to lock the front door may be revoked by the Director
should the club violate any of the Laws or Administrative Rules of the State of Arizona.
I,
) ________________________________________________________, hereby declare that I am the APPLICANT filing this
(Print Full Name
application. I have read the application and the contents and all statements are true, correct and complete.
State
County of
___________________
__________________
X __
__________________________________________
The foregoing instrument was acknowledged before me this
(
Signature)
My Commission Expires on: ____________________
_________day of ___________________________, _________________
Day
Month
Year
_____________________________________________________________
(Signature of Notary Public)
8/24/2015
Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-9027
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