MAINE DEPT OF PUBLIC SAFETY STATE OF MAINE Liquor Licensing & Inspection Division 164 State House Station Augusta ME 04333-0164 Tel: (207) 624-7220 Fax: (207) 287-3424 APPLICATION FOR B.Y.O.B. FUNCTION $10.00 (Per Day) Check Payable: Treasurer State of Maine Name of Applicant _____________________________________________________________ Address _____________________________ Town/City: ___________________ State: ____ Telephone (Day) _____________________ Fax: ______________________ If Organization, name of person responsible: _________________________________________ Birth of Date of Applicant(s): _____________________________________________________ Location of Function: ___________________________________________________________ Address: _________________________________________ City/Town: ________________ Describe specific area to be licensed: _______________________________________________ Date of Function: ______________ Time – From: ________ To: ________ Number of Persons attending: ___________________________ _______________________________________ Signature of Person Responsible _____________________ Date _____________________________________________ Print Name of Person Responsible FOR USE ONLY BY DEPT. OF PUBLIC SAFETY – LIQUOR LICENSING RESTRICTIONS: [ ] APPROVED – PERMIT # ________ DATED: __________ [ ] NOT APPROVED ISSUED BY: ______ BYOBApp /2003 American LegalNet, Inc. www.FormsWorkflow.com This permit is not assignable and is valid for use only by the applicant named heron for the date, time, and location indicated heron. This permit is issued subject to the Laws, Rules and Regulations of the Division and is issued subject to the penalties as provided for in Title 28A, Chapter 33. NOTE: MUNICIPAL OFFICERS & COUNTY COMMISSIONERS: This application must be approved by the Municipal Officers of the municipality in which the function is to be held or, if held in an unincorporated place, by the County Commissioner. Title 28A, Section 1076, Subsection 7D grant authority for this approval without public notice. STATE OF MAINE Dated at: _____________________________________, Maine _______________________________ ss City/Town (County) On: _________________________________________ Date The undersigned being: ‫ ڤ‬City ‫ ڤ‬Town ‫ ڤ‬Municipal Offices ‫ ڤ‬Plantation ‫ ڤ‬County Commissioners ‫ ڤ‬Unincorporated Place of the of: ______________________, Maine Hereby certify that we have given public notice on this application and held public hearing thereon as required by Section 653 Title 28A, Maine Revised Statutes and herby approve said application. Signature Print 72 Hours in Advance of Said Event or Gathering REQUESTED BYOBApp /2003 American LegalNet, Inc. www.FormsWorkflow.com