State of Alaska CATERER'S PERMIT Alcoholic Beverage Control Board 5848 E Tudor Rd Anchorage, Alaska 99507 Phone: 907-269-0350 FAK 907-272-9412 www.dps.state.ak.us/abc Permit No._______________ Fee: $50.00 Fee Paid______________ NOTICE TO APPLICANT: After approval by the appropriate law enforcement authority, send both parts of the completed form along with the $50 permit fee to the Alcoholic Beverage Control Board. When the permit has been approved, part I will be returned to you for posting at the event. Within 48 hours after the event has ended, return the posted copy to the Alcoholic Beverage Control Board. Name of Licensee(s) Beverage Dispensary License Number Contact Person and Phone Number Doing Business As Location of Premises Licensee's FAX Number Mailing Address (Street or P.O. box, City, State and Zip Code) The licensee named above hereby makes application under AS 04.11.230 for permission to cater the event described below. Event Person(s) designated by Licensee(s) to dispense alcoholic beverages Name Date of Birth AK Dr.Lic.No. Purpose Date of Event Time of Event-Beginning/Ending' Event To Be Held At: (Name and location of premise to be licensed) I/WE certify this written notice is submitted as required by AS 04.11.230 and will be returned within 48 hours after the event has ended. Any person observed to be giving or selling alcoholic beverages to a person under the age of 21 or an drunken person may be cited under AS 04.16.030, AS 04.16.040, AS 04.16,050, AS 04.16.05 1, AS 04.16.052 or AS 04.16.060. SIGNATURE OF LICENSEE(S) _________________________________________________________________________________________ Approved Disapproved Approved Disapproved by _____________________________________________ Date __________________________ Alaska State Troopers (OR) by _____________________________________________ Date __________________________ City Police Department Reason Disapproved: __________________________________________________________________________________________________ This permit authorizes the licensee(s) of a beverage dispensary license to cater this event an ft date and at the location requested and the licensee(s) is hereby notified that any violation of any Alcoholic Beverage Control Board Statute or regulation will be charged against the licensee(s). This permit will be issued unless a protest is noted by the appropriate police authority, or if the Director finds that it would not be in the best interest of the public. Approved Disapproved by _____________________________________________ Date __________________________ Alcohol Beverage Control Board DIAGRAM OF PREMISES TO BE LICENSED (OUTLINE AREA(s) FOR SALE AND CONSUMPTION OF ALCOHOLIC BEVERAGES IN RED (on separate sheet of paper) American LegalNet, Inc. www.FormsWorkflow.com