APPLICATION FOR TEMPORARY BEER / WINE PERMIT FOR ATC USE ONLY Type of permit State Form 35494 (R6 / 10-06) Approved by State Board of Accounts 1996 118 Amount received INSTRUCTIONS: 1. You must attach floor plan Permit number 2. You must obtain authority from local officials. TM STEP 1. MAILING INSTRUCTIONS Return permit to : Address (number and street ) City, ZIP code Telephone number STEP 2. GENERAL INFORMATION Name of applicant (organization, club, corporation, individual) Name of person making application Address of applicant (number and street, city, state, ZIP code) County of event Telephone number of person making application Date(s) (month, day, year ) From: To and including: Hours of event From: AM PM Exact address of event (number and street, city, state, ZIP code) AM To: PM Jurisdiction (town, city, county name ) STEP 3. EVENT INFORMATION 1. State the name of person in charge (in case of emergency ) Telephone number 1 Telephone number 2 2. Is the event open to the public? Yes No 3. Has the applicant or any partner or any officer ever been convicted of a felony, misdemeanor, or a violation of the ATC laws? Yes No If yes, explain: 4. How many persons can you expect in daily attendance? Security provided Yes No If yes, name of security _______________________________________ 5. Name of event: Not-for-profit For profit 6. Is the applicant, partnership, or corporation the holder of any kind of Indiana alcoholic beverage permit? If Yes, state: Yes a. type of permit No b. permit number c. name on permit American LegalNet, Inc. www.FormsWorkflow.com STEP 4. ACKNOWLEDGEMENT In order to qualify for a temporary permit, the following guidelines must be met: 1. There must be a well defined premises, i.e. building, tent, enclosure, or fenced-in or designated area. 2. You must submit a floor flan or diagram (8 1/2 x 11) showing either a beer garden / bar room (for adults only ) or beer garden / bar room and family area (for families to consume food ). All alcoholic beverages must be dispensed from the beer garden / bar room. Minors will be allowed in the family area with a parent or guardian to consume food. 3. There shall be NO carry-out privileges, NO carry-in privileges, and NO spirituous beverages allowed. 4. Each applicant must designate an individual to be responsible for the event and such person must sign the application. 5. ANY and ALL persons dispensing or selling, or accepting payment for alcoholic beverages MUST POSSESS a valid ATC employee permit. 6. The event must meet applicable Board of Health requirements, particularly with regard to restroom facilities. 7. Legal hours of dispensing alcoholic beverages ( Prevailing time ) Monday through Saturday -- 7a.m. to 3 a.m. the following day Sunday -- 10:00 a.m. to 12:30 a.m. the following day 8. Applicant must file with the ATC at least 15 days prior to the event. Failure to comply is grounds for denial. 9. The temporary permit must be posted in the most conspicuous place at the location of the event. An excise officer or commissioner, for good cause, has the authority to revoke a temporary permit during the event. The applicant, swears or affirms under penalties of perjury that the information in this application is true and accurate. The applicant also acknowledges the following: Initial It is a crime to drive with a blood-alcohol content of .08. It is a class B Misdemeanor, punishable by up to 6 months in jail and a $1,000 fine for knowingly serving an intoxicated person. That an excise officer may enter, inspect, and search your premises without a warrant and you must produce your permit on demand. That an excise officer may, for good cause, revoke a temporary permit during the event. Signature Date (month, day, year ) STEP 5. COMMUNITY CLEARANCE SIGNATURES MUST BE RECEIVED IN ORDER LISTED Before the Commission will consider the issuance of such temporary alcoholic beverage permit, the following signatures of the law enforcement officials of the community shall be obtained: We, the undersigned, hereby do not object to the issuance of a temporary alcoholic beverage permit to: 1. Signature of Sheriff of county, Chief of Police, or Town Marshall of jurisdiction where event will be held Date signed 2. Signature of the mayor (if the event is held in Ft. Wayne) Date signed 3. Signature of Excise Police representative Date signed STEP 6. COST OF PERMITS 1. ALL EVENTS ARE $50.00 PER DAY. 2. SERVING PAST MIDNIGHT, NO LATER THAN 3 A.M., IS ONE DAY. 3. NO RAIN CHECKS ON ANY OF THE ABOVE EVENTS. RETURN COMPLETED APPLICATION AND PROPER FEE TO THE LOCAL EXCISE OFFICE AT LEAST 15 DAYS PRIOR TO EVENT INFORMATION ON HOW TO CONTACT YOUR LOCAL EXCISE OFFICE CAN BE FOUND AT http://www.in.gov/isep Page 2 American LegalNet, Inc. www.FormsWorkflow.com