12072006 LOUISIANA DEPARTMENT OF REVENUE OFFICE OF ALCOHOL AND TOBACCO CONTROL P.O. BOX 66404 BATON ROUGE, LOUISIANA 70896-6404 TELEPHONE (225) 925-4041 – FAX (225) 925-3975 APPLICATION FOR CATERER’S PERMIT INSTRUCTIONS: APPLICATION MUST BE COMPLETE WITH PROPER FEES OF $200 ATTACHED. PLEASE TYPE OR PRINT IN INK. Owner name (individual partnership, LLC, Corporation) Trade Name Mailing Address PO Box,/Street/City/State/Zip Phone No. Location Address PO Box/Street/City/State/Zip Parish DO YOU HAVE AN CURRENT CLASS A OR B PERMIT? YES IF YES, PERMIT NUMBER? NO EXPIRATION DATE? IF NO: (1) DO YOU OPERATE A FULLY-EQUIPPED KITCHEN? YES NO (2) DO YOU DERIVE 70 PERCENT OF YOUR GROSS ANNUAL REVENUE FROM THE SALE OF FOOD OR FOOD- RELATED PRODUCT? YES NO (3) DO YOU DERIVE 40 PERCENT OF YOU GROSS REVENUE PER EVENT FROM THE SALE OF FOOD OR FOOD-RELATED PRODUCT? YES NO (4) DO YOU MAINTAIN SEPARATE SALES FIGURES FOR ALCOHOLIC BEVERAGES? YES NO (5) HAVE YOU INCLUDED AN ADDITIONAL $50 FEE FOR THE RESPONSIBLE VENDOR PROGRAM? YES NO ***COMPLETED SCHEDULE A FORMS MUST ALSO BE EXECUTED AND SUBMITTED BY THE MANAGER, OWNER, EACH PARTNER, EACH OFFICER, AND STOCKHOLDER OWNING MORE THAN 5 PERCENT OF THE CAPITAL STOCK. AFFIDAVIT This affidavit must be signed by owner, if individual ownership; authorized partner, if partnership; or authorized official if corporation or LLC. It is understood any misstatement or suppression of fact in this application or accompanying documents is grounds for denial. I swear (or affirm) that I have read each of the questions in this application and that the answers which I have given are true and correct to the best of my knowledge and that I meet the qualifications and will abide by the conditions set forth in R.S. 26:80 and 280, and LAC 55:VII.325; and I further swear (or affirm) that I have no interest in any entity holding a state wholesale beer or liquor permit. Applicant’s Signature: ______________________________________________________________ Title: Print/Type your name: Sworn to and subscribed to me this In the parish of day of , 20 , State of Notary Public’s Signature: ________________________________________________ Print Name of Notary Public: American LegalNet, Inc. www.FormsWorkflow.com