Unlicensed Business Establishment Application For Exemption
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Unlicensed Business Establishment Application For Exemption Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
Tags: Unlicensed Business Establishment Application For Exemption, LIC0121, Arizona Statewide, Liquor Licenses And Control
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.
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