State of California Department of Alcoholic Beverage Control CATERING AUTHORIZATION APPLICATION LICENSE NUMBER Please read instructions before completing form. RECEIPT NUMBER TOTAL FEE $ SECTION 1 1. LICENSEE NAME(S) (If an individual, first name, middle name, last name.) 2. CONTACT PERSON 3. CONTACT PHONE NUMBER 4. LICENSED PREMISES ADDRESS 5. MAILING ADDRESS (IF DIFFERENT) 6. EVENT LOCATION (Street number and name, city, zip code) 7. DESCRIPTION OF LOCATION (Parking lot, office building, residence, county/city park, etc.) 8. EVENT LOCATION IS WITHIN THE CITY LIMITS 9. EVENT DATE(S) 10. TOTAL NUMBER OF DAY(S) Yes 11. EVENT HOURS No 12. EVENT OPEN TO THE PUBLIC 13. ESTIMATED ATTENDANCE From To Yes No SECTION 2 14. EVENT TYPE CATERING EVENT Trade Exhibit Picnic Social Gathering Wedding Anniversary Birthday 15. NUMBER OF EVENTS CATERED THIS YEAR AT THIS LOCATION (Not applicable to club licensees) Convention Sporting Event Other 16. ORGANIZATION SPONSORING EVENT 17. PERSON IN CHARGE OF EVENT 18. MAILING ADDRESS 19. PHONE NUMBER OF ABOVE PERSON SECTION 3 20. SUPPLIER NAME EVENT AUTHORIZED PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 25600.5 21. SUPPLIER LICENSE NUMBER 22. SUPPLIER CONTACT PERSON 23. SUPPLIER CONTACT PHONE NUMBER SECTION 4 I declare under penalty of perjury that to the best of my knowledge these statements are true and correct. LICENSEE SIGNATURE DATE SIGNED SECTION 5 SIGNATURE LOCAL LAW ENFORCEMENT AGENCY APPROVAL (IF APPLICABLE) TITLE DATE SIGNED SECTION 6 PROPERTY OWNER APPROVAL REQUIRED AUTHORIZATION (For ABC Use Only) CONDITIONS/ACKNOWLEDGMENTS REQUIRED DIAGRAM REQUIRED LAW ENFORCEMENT APPROVAL REQUIRED Yes, attached No Yes, attached No Yes, attached No Yes DATE SIGNED No DISTRICT APPROVAL BY (Name) ABC EMPLOYEE SIGNATURE ABC-218 (rev. 01/14) American LegalNet, Inc. www.FormsWorkFlow.com