Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street Suite 222, St. Paul MN 55101-5133 (651) 201-7507 Fax (651) 297-5259 TTY (651) 282-6555 WWW.DPS.STATE.MN.US APPLICATION AND PERMIT FOR A 1 TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE TYPE OR PRINT INFORMATION NAME OF ORGANIZATION DATE ORGANIZED TAX EXEMPT NUMBER STREET ADDRESS CITY STATE NAME OF PERSON MAKING APPLICATION BUSINESS PHONE ( ) DATES LIQUOR WILL BE SOLD ORGANIZATION OFFICER'S NAME TYPE OF ORGANIZATION CLUB CHARITABLE RELIGIOUS ADDRESS ORGANIZATION OFFICER'S NAME ADDRESS ORGANIZATION OFFICER'S NAME ADDRESS ZIP CODE HOME PHONE ( ) OTHER NONPROFIT Location license will be used. If an outdoor area, describe Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. Will the applicant carry liquor liability insurance? If so, please provide the carrier’s name and amount of coverage. APPROVAL APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING ENFORCEMENT CITY/COUNTY___________________________ DATE APPROVED_________________________ CITY FEE AMOUNT ______________________ LICENSE DATES __________________________ DATE FEE PAID _________________________ SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT NOTE: Submit this form to the city or county 30 days prior to event. Forward application signed by city and/or county to the address above. If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for the event PS-09079 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com