DEPARTMENT OF LIQUOR CONTROL � COUNTY OF MAUI 2145 Kaohu Street, Room 105, Wailuku, Hawaii 96793 � Phone 243-7030 788 Pauoa Street, Room 102, Lahaina, Hawaii 96761 � Phone 661-9581 APPLICATION FOR SPECIAL LIQUOR LICENSE Applicant: Trade Name: hereby makes the following application for a special license for a fundraising event as provided by the provisions of Chapter 281 of the Hawaii Revised Statutes, as amended by Act 148. 1. "SPECIAL": Class & Kind EFFECTIVE DATES & TIMES: LOCATION: 2. OFFICERS/DIRECTORS TITLE AGE PLACE OF RESIDENCE 3. Name of person who will be present at the event and be in active charge: 4. If premises to be used is a State or County facility, a permit will be required to allow the dispensing of alcoholic beverages. I hereby certify all necessary clearances from other government agencies have been obtained in reference to this application. DATE: BY: Signature Print Name and Position FOR OFFICE USE ONLY Date received: Recommended by: Approved for the Liquor Commission by the Director: License Fee: Application No.: Grant [ ] Refuse [ ] Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DLC-016 [rev. 04/10] DEPARTMENT OF LIQUOR CONTROL � COUNTY OF MAUI 2145 Kaohu Street, Room 105, Wailuku, Hawaii 96793 � Phone 243-7030 788 Pauoa Street, Room 102, Lahaina, Hawaii 96761 � Phone 661-9581 APPLICATION FOR SPECIAL LIQUOR LICENSE These are the employees who will be serving liquor at the gathering in our premises: NAME AGE We have designated from our staff Mr/Ms to supervise the service and consumption of liquor for this occasion. By: Cell Phone #: Signature Print Name and Position Date: Phone Number: Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DLC-016 [rev. 04/10]