Idaho State Police ALCOHOL BEVERAGE CONTROL P.O. Box 700 Meridian, ID 83680-0700 (208) 884-7060 APPLICATION FOR BEER/WINE PERMIT □ Beer Permit ($20) □ Wine Permit ($20) □ Both Beer and Wine Permit ($40) (Check one) Applicant Name: _______________________________________________________ State or Federal Tax ID #_____________________ Mailing Address: _________________________________________________________________________________________________ (Address) (City) (State) (Zip Code) Dates of event: ________________________________________________(Not to Exceed 3 Days) Hours of Event: ___________________ (Please include a.m. or p.m.) Location of event: _________________________________________________________________________________________________ (Name) (Address) (City) Name of Event: ____________________________________________________________________________________________________ Is the location of the event inside city limits? Yes_________ No_________ Purpose: _________________________________________________________________________________________________________ Sponsors: ________________________________________________________________________________________________________ Proceeds will be donated to: __________________________________________________________________________________________ PROVIDERS OF BEER BRAND OF BEER PROVIDERS OF WINE BRAND OF WINE Retailer Designated to Receive, Store, Dispense Beer or Wine: ______________________________________________________________ I HEREBY CERTIFY THAT THE APPLICANT LISTED ABOVE IS NOT OTHERWISE LICNESED IN THE STAE OF IDAHO TO SELL ALCOHOLIC BEVERAGES AND THE PROCEEDS FROM THIS EVENT WILL BE DONATED FOR BENEVOLENT, CHARITABLE, OR PUBLIC PURPOSES. Applicant Signature_____________________________ Title ______________________ Date_____________________________________ Phone Number_____________________________________________________________________________________________________ Subscribed and sworn to this _______________________________________day of _________________________________, 20_________ __________________________________________________ Notary Public Residing at_____________________________________________________ Commission Expires______________________________________________ American LegalNet, Inc. www.FormsWorkflow.com