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 UNLICENSED BUSINESS ESTABLISHMENTAPPLICATION FOR EXEMPTION THIS EXEMPTION, IF APPROVED, IS VALID FOR ONLY 1 YEAR (12 MONTHS) FROM THE DATE OF APPROVAL. A NEW APPLICATION FOR EXEMPTION MUST BE SUBMITTED EACH YEAR. NEW APPLICATIONS MUST BE SUBMITTED PRIOR TO EXPIRATION OF THE EXISTING EXEMPTION FOR UNINTERRUPTED EXEMPT STATUS. Date: I, doing business as Owner’s Name Name of Business Establishment ( Establishment Address City County Zip Code ) Establishment Phone hereby request permission from the Director of The Department of Liquor Licenses and Control to allow my patrons to consume allowable alcoholic beverages on my unlicensed premises. I have received and read a copy of the Rules governing A.R.S. Section 4-244.05. I declare that my business is one that qualifies for exemption under R19-1-315 and I claim exemption as one of the following as defined by R19-1-315.6: Small Restaurant (R19-1-315.6.a Association (R19-1-315.6.c Catering Establishment (R19-1-315.6.b Business Establishment Private Social Function (R19-1-315.6.d I hereby agree to adhere to the Director’s Rules R19-1-315 and the additional Rules as outlined in A.R.S. 4-244.05. I further understand that any violations of these rules may result in a fine and civil penalty as prescribed by A.R.S. Section 4-244.05.C. Applicant’s Address ( City State ) ( Contact Phone Numbers: ) Business I, Zip Residence , being first duly sworn upon oath, hereby depose, swear and declare (Print full name) that I am the APPLICANT filing this application. I have read this declare under penalty of perjury, that I am the APPLICANT making foregoing aapplication and that the application has been read and that the contents thereof and and all statements contained therein are true, correct and complete. State of County of The foregoing instrument was acknowledged before me this day of (Signature of Applicant) , Day Month Year My commission expires on: (Signature of NOTARY PUBLIC) Do not write or make any marks in this box FOR DEPARTMENT USE ONLY APPROVED EXPIRATION DATE: DISAPPROVED BY: DATE: FILE # UL: LIC0121 05/200 *Disabled individuals requiring special accommodations please call the Department. American LegalNet, Inc. www.FormsWorkflow.com