Schedule Temporary 01/01/07 COMMONWEALTH OF KENTUCKY OFFICE OF ALCOHOLIC BEVERAGE CONTROL 1003 Twilight Trail Frankfort, Kentucky 40601-8400 (502) 564-4850 phone (502) 564-1442 fax http://abc.ky.gov Site I.D. # SCHEDULE "TEMPORARY" LICENSE Applications may be returned if all questions are not answered completely. LEAVE BLANK – FOR ABC USE ONLY License # ______________ $_______________ Val._______________ License #_______________ $_______________ Val. ____________ License # ______________ $_______________ Val._______________ License# _______________ $_______________ Val. ____________ Malt Beverage Administrator’s Approval _____________________________________________________ Date ___________________________ Distilled Spirits Administrator’s Approval ____________________________________________________ Date ___________________________ (A). Name of person(s) or company to be licensed ____________________________________________________________________________ Name of this special event _______________________________________________________________________________________________ Address of premises to be licensed ________________________________________________________________________________________ (Where the alcoholic beverages will be sold) City __________________________________ County _________________________ State ________ 9 digit zip code ____________________ Mailing address if different from above _____________________________________________________________________________________ Contact person 8:00 am – 4:30 pm ______________________________________________________ e-mail address _____________________ Contact phone__________________________________________________________Fax ___________________________________________ List the type(s) of temporary license(s) you are applying for ____________________________________________________________________ (B). 1. Amount of fee enclosed…(Make certified check, cashier check or money order payable to Kentucky State Treasurer)……. $_______. 2. Period to be covered by license from (month) __________________(day) _________(year) ________. Through (See fee chart on the back page of this application) (Month) __________________(day) _________(year) ________. (Each event requires a separate application, fee and license.) 3. WHAT IS THE DATE (S) AND TIME (S) OF YOUR SPECIAL EVENT? __________________________________________________. 4. Kentucky law limits temporary licenses to public events. Therefore, do you agree not to exclude the public from this special event? 5. ⃞ Yes ⃞ No Are you the owner of the real estate where the premises are to be licensed? ⃞ Yes ⃞ No If no, attach a copy of your lease or letter of permission to use this property, signed by you and the owner of the real estate. List the real estate owner’s name. _________________________________________________________________. SOCIAL SECURITY NUMBER TITLE H W F O ⃞ Yes H W F O ⃞ Yes ⃞ No ⃞ No DATE OF BIRTH % OF OWNERSHIP ALL PHONE NUMBERS H = HOME W = WORK F = FAX 0 = OTHER LIST DATE & STATE WHERE YOU RESIDED IN PAST 5 YRS. NAME AND ADDRESS USA CITIZEN (C). 6. Complete the following for the business proprietor, partner(s) and all persons interested in the business to be licensed. List all owners, officers, directors, partners, managing members, members, and shareholders (unless publicly held). Show 100% of the ownership. If additional space is needed, please make an attachment. % % American LegalNet, Inc. www.FormsWorkflow.com Schedule Temporary 01/01/07 (D). 7. Site ID # Are the premises to be licensed located within an incorporated city or town? If yes, list the name of the city or town. __________________________________________________________. ⃞ Yes ⃞ No 8. Is the entire license fee paid by the applicant and by no other person? ⃞ Yes ⃞ No 9. Is the applicant a corporation, limited partnership, or limited liability company, in good standings with the Kentucky Secretary of State? ⃞ Yes ⃞ No 10. Has the applicant(s) been licensed to sell alcoholic beverages? If yes, list your state ABC license number(s)._______________________________________________________. ⃞ Yes ⃞ No 11. Has the applicant or any person named in statement 6 been convicted of any felony in the past five (5) years? Has the applicant or any person named in statement 6 been convicted of a misdemeanor directly or indirectly related to alcohol or a controlled substance in the past two (2) years? If yes, you must attach a statement giving a full explanation, including dates of convictions. ⃞ Yes ⃞ No 12. Has the premises to be licensed or any person listed in this application had a ABC license suspended or revoked, or an ABC application denied? If yes, you must attach a statement giving a full explanation, including dates of suspension, revocation or denial. ⃞ Yes ⃞ No ⃞ Yes ⃞ No 13. Give a brief description of the purpose for this special temporary license. 14. List the persons or non-profit, charitable, civic or political organization that will receive the proceeds from the sales of alcoholic beverages under this Special Temporary License. (E). AFFIDAVIT OF PERSON APPLYING FOR THE KENTUCKY ABC LICENSE(S) I do hereby solemnly swear or affirm that all statements contained in this application and all attachments are true and correct to the best of my knowledge, information and belief. I understand I may not begin to operate with alcohol activity until the Kentucky ABC Office has issued my license(s). I further swear or affirm I shall abide by all state and local statutes, regulations, and ordinances relating to the manufacture, sale, use of and trafficking in alcoholic beverages. Signature of Applicant _______________________________________________Title _________________________________Date ___________ Sworn or affirmed before me on this _______day of _____________, year of _______. My commission expires _________________________ Notary Public ____________________________________________________County of _____________________, Commonwealth of Kentucky (F). OBTAIN SIGNATURE OF YOUR LOCAL ABC ADMINISTRATOR Your Local ABC Administrator must approve this application schedule before it is forwarded to the State ABC. Take or mail this application schedule, fee and all attachments to your Local ABC Administrator. Obtain their signature of approval below or make arrangements for this approval to be sent to the State ABC Office in Frankfort, Kentucky This certifies that the application(s) herein above named have been approved for the type(s) of licenses applied for and for the premises above specified. SIGNATURE OF APPROVAL OF LOCAL ABC ADMINISTRATOR ________________________________________________DATE ___________ City of________________________________________Administrator or the County of ________________________________Administrator _______________________________________________________________________________________________________________________ (G). You may now forward this application schedule, all attachments, and your state license fee to: Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Telephone (502) 564-4850 Fax (502) 564-1442 American LegalNet, Inc. www.FormsWorkflow.com Site ID # ABC Temporary 01/01/07 TYPES OF LICENSES & FEES Checkb the boxes for the type(s) of license(s) you are applying for. To determine the ABC license fee(s), find the license type(s) in the left column, then move right across the table. Attach a certified check, cashier check, or a money order. Make check payable to: KENTUCKY STATE TREASURER NO CASH! LICENSE TYPE PREFIX PER EVENT FEE TB ⃞ 50.00 TW ⃞ 50.00 TD TEMPORARY BEER BY THE DRINK b ⃞ 100.00 TA ⃞ 100.00 Under Ky. Revised Statute KRS 243.290 & 804 KAR 4:250 TEMPORARY WINE BY THE DRINK Under Ky. Revised Statute & Adm. Reg. KRS 243.260 & 804 KAR 4:250 TEMPORARY LIQUOR AND WINE BY THE DRINK Under Ky. Revised Statute & Adm. Reg. KRS 243.260 & 804 KAR 4:250 TEMPORARY LIQUOR AND WINE AUCTION BY THE PACKAGE Under Ky. Revised Statute KRS 243.036 TOTALS CHECK LIST 1. Have you attached a certified check, cashier check, or a money order, payable to: Kentucky State Treasurer? We do not accept cash! ⃞ Yes ⃞ No 2. Have you answered each question fully and checked the type(s) of license(s) you are applying for? ⃞ Yes ⃞ No 3. Have you signed and had your application(s) notarized? ⃞ Yes ⃞ No 4. If the applicant is “For Profit”, have you attached a letter from the non-profit, charitable, civic or political organization receiving the proceeds or benefiting from this event? ⃞ Yes ⃞ No 5. Have you attached a lease or letter of permission from the owner of the real estate? ⃞ Yes ⃞ No⃞ N/A 6. Have you had this application signed and approved by your local ABC Administrator? ⃞ Yes ⃞ No ⃞ None You may now forward this application schedule, all attachments, and your state license fee to: Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Telephone (502) 564-4850 Fax (502) 564-1442 http://abc./ky.gov/ American LegalNet, Inc. www.FormsWorkflow.com