Supplement License & Hall Rental Request Form Liquor License Number_______________ Name _________________________ Phone Number ______________________ Address________________________________ Mailing Address__________________________ _____________________________ _______________________ Please check type of rental (Supplemental is when you are selling alcohol to party renting hall-NOT FOR CLUB FUNCTIONS). This form may be filled out for multiple functions. Any requests for gambling functions must be accompanied by a copy of the gambling permit issued for event. All requests MUST be received 5 Day’s prior to first date requested. _________ ___________ _____ Supplemental Hall rental Bingo _________ _______ ____________________ Date Start time End time ________________ _____________________ Event Name of party renting hall _________ Supplemental _________ Date ________________ Event ___________ Hall rental _______ Start time _____ Bingo ____________________ End time _____________________ Name of party renting hall _________ Supplemental _________ Date ________________ Event ___________ Hall rental _______ Start time _____ Bingo ____________________ End time _____________________ Name of party renting hall _________ Supplemental _________ Date ________________ Event ___________ Hall rental _______ Start time _____ Bingo ____________________ End time _____________________ Name of party renting hall _________ Supplemental _________ Date ________________ Event ___________ Hall rental _______ Start time _____ Bingo ____________________ End time _____________________ Name of party renting hall MAIL REQUEST TO: NHSLC, PO BOX 1795, CONCORD NH 03302-1795 Rev. 04/3/06 American LegalNet, Inc. www.FormsWorkflow.com