Print Form ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 800 W Washington 5th Floor Phoenix, AZ 85007-2934 www.azliquor.gov (602) 542-5141 APPLICATION FOR PRIVATE CLUB LOCKED FRONT DOOR Series No. 14 (ARS 4-205) only 1. Club Name ______________________________________________________ Club License Number ____________________________ (Exactly as it appears on license) 2. Club/License Location _____________________________________________________________________________________________ Address City Zip 3. Agent’s Name __________________________________________________________________________________________________ Last First Middle 4. Mailing Address __________________________________________________________________________________________________ Address City Zip 5. Business Phone:(______)_________________Residence Phone:(______)_________________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 if n needed.) ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ 7. Local law enforcement authority has reviewed this application. Comments, if any, by the local law enforcement agency man be 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 enforcment officers, fire fighters and emergency medical personnel. We understand that permission to lock the front door may be revoked by the director should the the club violate any of the Laws or Admnistrative 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 of __________________ County of ____________________ X ________________________________________________________ The foregoing instrument was acknowledged before me this Signature of Applicant ____________ of ___________________, _______________ Day My commission expires on: ______________________________ Month Year __________________________________________________ (Signature of Notary Public) Lic 1005 05/2009 *Disabled individuals requiring special accomodations, please call the department. American LegalNet, Inc. www.FormsWorkFlow.com ARS. 4-228. FRONT ENTRANCE LOCK PROHIBITED; EXCEPTION A. EXCEPT AS PROVIDED IN THIS SECTION, AN ON-SALE LICENSEE SHALL NOT LOCK OR PERMIT TO BE LOCKED THE FRONT ENTRANCE TO A LICENSED ESTABLISHMENT UNTIL ALL PERSONS OTHER THAN THE LICENSEE OR THE LICENSEE’S EMPLOYEES ON DUTY HAVE LEFT THE PREMISES. THIS SECTION DOES NOT PROHIBIT LOCKING THE PREMISES IMMEDIATELY AFTER THE CLOSING OF THE PREMISES IF AN EMPLOYEE AND ONE OTHER PERSON REMAIN ON THE PREMISES. B. IF THE HOLDER OF A CLUB LICENSE ISSUED PURSUANT TO SECTION 4-205 HAS BONA FIDE CONCERNS REGARDING THE SAFETY OF CLUB MEMBERS AND THEIR GUESTS, THE LICENSEE MAY APPLY TO THE DIRECTOR FOR PERMISSION TO LOCK THE FRONT ENTRANCE TO THE LICENSED ESTABLISHMENT. THE APPLICATION SHALL BE ON A FORM PRESCRIBED BY THE DIRECTOR AND SHALL INCLUDE A DESCRIPTION OF THE SAFETY CONCERNS. C. THE DIRECTOR SHALL DETERMINE IN THE DIRECTOR’S DISCRETION WHETHER TO GRANT PERMISSION TO LOCK THE FRONT ENTRANCE TO A CLUB LICENSE. THE DIRECTOR SHALL CONSIDER, AMONG OTHER FACTORS, THE SAFETY CONCERNS DOCUMENTED BY THE CLUB LICENSEE AND THE LOCATION, METHOD OF OPERATION AND REGULATORY HISTORY OF THE CLUB. FIRE FIGHTERS, LAW ENFORCEMENT OFFICERS, EMERGENCY MEDICAL PERSONNEL AND THE DIRECTOR SHALL HAVE IMMEDIATE ACCESS BY MEANS OF A MASTER KEY, MASTER CARD OR OTHER SIMILAR DEVICE TO THE LICENSED ESTABLISHMENT AT ALL TIMES THAT THE ESTABLISHMENT IS OCCUPIED. AT ANY TIME THE DIRECTOR MAY REVOKE PERMISSION TO LOCK THE FRONT ENTRANCE GRANTED PURSUANT TO THIS SECTION. 6 a. Additional applicant explanation of request: 7 a. Local law enforcement agency comments: DIRECTOR APPROVES DISAPPROVES APPLICATION for Private Club locked front door. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com