Department of Alcoholic Beverage Control State of California ARNOLD SCHWARZENEGGER, Governor DAILY LICENSE APPLICATION/AUTHORIZATION - Non Transferable LICENSE NUMBER Instructions: Complete all items. Submit to local ABC District Office with required fee (Cashier's Check or Money Order) payable to ABC. Once license is issued, fee cannot be refunded. For a listing of ABC District Offices please visit http://www.abc.ca.gov/distmap.html Pursuant to the authority granted by the organization named below, the undersigned hereby applies for the license(s) described below. GEO CODE RECEIPT NUMBER FEE $ 1. ORGANIZATION'S NAME CONDITIONS REQUIRED Yes DIAGRAM REQUIRED No Yes No 2. LICENSE TYPE (Check appropriate license type AND organization type) Daily General ($25.00) (Includes beer, wine and distilled spirits) a. Political Party/Affiliate Supporting Candidate for Public Office or Ballot Measure Fraternal Organization in Existence Over Five Years with Regular Membership Organization Formed for Specific Charitable or Civic Purpose Religious Organization Other: Vessel per Section 24045.10 B&P ($50.00) NUMBER OF DISPENSING POINTS b. Special Daily Beer ($25.00) Special Daily Beer & Wine ($50.00) Charitable Social Political Civic c. Fraternal Religious Cultural Special Daily Wine ($25.00) Amateur Sports Organization Special Temporary License ($100.00) Other: NUMBER OF DISPENSING POINTS (Different privileges depending on statute) Television Station per Section 24045.2 or 24045.9 B&P Person conducting Estate Wine Sale per Section 24045.8 B&P Nonprofit Corporation per Sections 24045.4 and 24045.6 B&P Women's Educational and Charitable Organization per Section 24045.3 B&P Other Special Temporary Licenses, per Section License number Amount $ 3. EVENT TYPE Dinner Sports Event 4. TOTAL # OF DAYS Dance Wedding Concert Birthday 5. ESTIMATED ATTENDANCE Lunch Picnic Barbeque Social Gathering Mixer Carnival Dinner Dance Festival Other: 6. HOURS OF ALCOHOLIC BEVERAGE SALES, SERVICE AND/OR CONSUMPTION From 7. EVENT DATE(S) To 8. EVENT IS OPEN TO THE PUBLIC Yes No 9. EVENT LOCATION (Give facility name, if any, street number and name, and city) 10. LOCATION IS WITHIN THE CITY LIMITS Yes 11. TYPE OF ENTERTAINMENT No 12. SECURITY GUARDS Yes No 13. AUTHORIZED REPRESENTATIVE'S NAME If yes, how many? 14. REPRESENTATIVE'S TELEPHONE NUMBER 15. REPRESENTATIVE'S ADDRESS 16. ORGANIZATION'S MAILING ADDRESS (If different from #15 above) 17. AUTHORIZED REPRESENTATIVE'S SIGNATURE 18. DATE SIGNED PROPERTY OWNER APPROVAL BY (Name), REQUIRED PHONE NUMBER PROPERTY OWNER SIGNATURE DATE SIGNED LAW ENFORCEMENT APPROVAL BY (Name), IF APPLICABLE PHONE NUMBER LAW ENFORCEMENT SIGNATURE DATE SIGNED ABC EMPLOYEE SIGNATURE ISSUANCE DATE DISTRICT OFFICE APPROVAL BY (Name) The above-named organization is hereby licensed, pursuant to the California Business and Professions Code Division 9 and California Code of Regulations, to engage in the temporary sale of alcoholic beverages for consumption at the above named location for the period authorized above. This license does not include off-sale ("to-go") privileges. This license may be revoked summarily by the Department if, in the opinion of the Department and/or the local law enforcement agency, it is necessary to protect the safety, welfare, health, peace and morals of the people of the State. ABC-221 (rev. 11/10) American LegalNet, Inc. www.FormsWorkFlow.com