ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 400 W Congress #521 Tucson AZ 85701-1352 (520) 628-6595 800 W Washington 5th Floor Phoenix AZ 85007-2934 (602) 542-5141 STORE SAMPLING REQUEST ARS §4-243(B)(3) MUST SUBMIT REQUEST AT LEAST 10 DAYS BEFORE SAMPLING DATE Complete this section. 1. Wholesaler/Producer Name:_______________________________________________________ 2. Wholesaler/Producer License Number: ______________________________________________ 3. Wholesaler/Producer Licensee/Agent Name: _________________________________________ Last First 4. Date of Sampling: _______________________________ 5. Time of Sampling: From _____ am / pm To: _____ am / pm Not to exceed 3 hours. 6. Name of Entity Hosting the Sampling: ______________________________________________ 7. Off-Sale Retailer Liquor License Number: ___________________________________________ 8. Sampling Address Location: ______________________________________________________ 9. Product(s) to be sampled: ________________________________________________________ 10. Description of proposed barrier: ___________________________________________________________ Requesting party conducting the sampling must be an agent or authorized owner representative listed on the Department of Liquor records for the wholesaler/producer conducting the sampling. I have read, understand, and agree to comply with the statutory requirements for conducting sampling at an off-sale retail location. Authorized Representative _____________________________________ Date:___________________________ _____________________________________ Title Approved Date Submitted: ________________ LCS checked by: _______________ Number of Events at this Location 1 2 3 4 5 6 7 8 9 10 11 12 Disapproved _____________________________________________ Investigations Circle One Department Use Only Lic 250 08/2005 American LegalNet, Inc. www.FormsWorkflow.com