DR 8439 (06/06/06) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 (303) 205-2300 Department Use Only APPLICATION FOR A SPECIAL EVENTS PERMIT IN ORDER TO QUALIFY FOR A SPECIAL EVENTS PERMIT, YOU MUST BE NONPROFIT AND ONE OF THE FOLLOWING (See back for details.) SOCIAL ATHLETIC PHILANTHROPIC INSTITUTION FRATERNAL CHARTERED BRANCH, LODGE OR CHAPTER POLITICAL CANDIDATE PATRIOTIC OF A NATIONAL ORGANIZATION OR SOCIETY MUNICIPALITY OWNING ARTS POLITICAL RELIGIOUS INSTITUTION FACILITIES LIAB 2110 2170 FERMENTED MALT BEVERAGE (3.2 Beer) DO NOT WRITE IN THIS SPACE TYPE OF SPECIAL EVENT APPLICANT IS APPLYING FOR: MALT, VINOUS AND SPIRITUOUS LIQUOR $25.00 PER DAY LIQUOR PERMIT NUMBER $10.00 PER DAY 1. NAME OF APPLICANT ORGANIZATION OR POLITICAL CANDIDATE State Sales Tax Number (Required) 3. ADDRESS OF PLACE TO HAVE SPECIAL EVENT (include street, city/town and ZIP) 2. MAILING ADDRESS OF ORGANIZATION OR POLITICAL CANDIDATE (include street, city/town and ZIP) NAME DATE OF BIRTH HOME ADDRESS (Street, City, State, ZIP) PHONE NUMBER 4. PRES./SEC'Y OF ORG. or POLITICAL CANDIDATE 5. EVENT MANAGER 6. 7. HAS APPLICANT ORGANIZATION OR POLITICAL CANDIDATE BEEN ISSUED A SPECIAL EVENT PERMIT THIS CALENDAR YEAR? NO YES IS PREMISES NOW LICENSED UNDER STATE LIQUOR OR BEER CODE? NO HOW MANY DAYS? YES TO WHOM? 8. DOES THE APPLICANT HAVE POSSESSION OR WRITTEN PERMISSION FOR THE USE OF THE PREMISES TO BE LICENSED? Yes No LIST BELOW THE EXACT DATE(S) FOR WHICH APPLICATION IS BEING MADE FOR PERMIT Date Hours Date From .m. To Hours .m. Date From .m. To .m. Hours Date From .m. To Hours Date From .m. .m. To .m. Hours From .m. To .m. OATH OF APPLICANT I declare under penalty of perjury in the second degree that I have read the foregoing application and all attachments thereto, and that all information therein is true, correct, and complete to the best of my knowledge. SIGNATURE TITLE DATE REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY OR COUNTY) The foregoing application has been examined and the premises, business conducted and character of the applicant is satisfactory, and we do report that such permit, if granted, will comply with the provisions of Title 12, Article 48, C.R.S., as amended. THEREFORE, THIS APPLICATION IS APPROVED. LOCAL LICENSING AUTHORITY (CITY OR COUNTY) SIGNATURE CITY COUNTY TELEPHONE NUMBER OF CITY/COUNTY CLERK DATE TITLE DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY LIABILITY INFORMATION License Account Number Liability Date TOTAL State -750 (999) (Instructions on Reverse Size) $ • American LegalNet, Inc. www.FormsWorkflow.com APPLICATION INFORMATION AND CHECKLIST THE FOLLOWING SUPPORTING DOCUMENTS MUST BE ATTACHED TO THIS APPLICATION FOR A PERMIT TO BE ISSUED: Appropriate fee. Diagram of the area to be licensed (not larger that 8 1/2" X 11" reflecting bars, walls, partitions, ingress, egress and dimensions. Note: If the event is to be held outside, please submit evidence of intended control, i.e., fencing, ropes, barriers, etc. Copy of deed, lease, or written permission of owner for use of the premises. Certificate of good corporate standing (NONPROFIT) issued by Secretary of State within last two years; or If not incorporated, a NONPROFIT charter; or If a political Candidate, attach copies of reports and statements that were filed with the Secretary of State. APPLICATION MUST FIRST BE SUBMITTED TO THE LOCAL LICENSING AUTHORITY (CITY OR COUNTY) AT LEAST THIRTY (30) DAYS PRIOR TO THE EVENT. THE PREMISES TO BE LICENSED MUST BE POSTED AT LEAST TEN (10) DAYS BEFORE A HEARING CAN BE HELD. (12-48-106 C.R.S.) AN APPROVED APPLICATION MUST BE RECEIVED BY THE LIQUOR ENFORCEMENT DIVISION AT LEAST TEN (10) DAYS PRIOR TO THE EVENT. CHECK PAYABLE TO THE COLORADO DEPARTMENT OF REVENUE (12-48-102 C.R.S.) A Special Event Permit issued under this article may be issued to an organization, whether or not presently licensed under Articles 46 and 47 of this title, which has been incorporated under the laws of this state for the purpose of a social, fraternal, patriotic, political or athletic nature, and not for pecuniary gain or which is a regularly chartered branch, lodge or chapter of a national organization or society organized for such purposes and being non profit in nature, or which is a regularly established religious or philanthropic institution, and to any political candidate who has filed the necessary reports and statements with the Secretary of State pursuant to Article 45 of Title 1, C.R.S. A Special Event permit may be issued to any municipality owning arts facilities at which productions or performances of an artistic or cultural nature are presented for use at such facilities. If an event is cancelled, the application fees and the day(s) are forfeited. American LegalNet, Inc. www.FormsWorkflow.com