ABCD 1000T1 (Revised 8/95) APPLICATION and AFFIDAVIT CLASS I TEMPORARY RETAILERS PERMIT RETURN TO ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS. 39130-0540 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR PROPER FILING OF YOUR APPLICATION PLEASE READ PRIOR TO COMPLETING THIS FORM 1. An application fee of $35.00, in the form of either a cashier’s check or a money order payable to the Alcoholic Beverage Control must be returned with this completed application. 2. The applicant’s signature must be notarized by a licensed Notary Public. 3. The alcoholic beverages used by you under this permit must be purchased from a Mississippi package retailer located within the county where your event is held. 4. This application, with fee, must be received at the Alcoholic Beverage Control at least two (2) weeks prior to the event to assure adequate time for processing and mailing of your permit. Applications received less than two weeks prior to the event may result in denial of the request. If you have questions or need assistance, please call ABC Permit Department 856-1330 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT AND APPLICATION FOR CLASS I TEMPORARY PERMIT I. APPLICANT: Name ________________________________________ (Nonprofit civic or charitable organization) Address: _____________________________________________ (street or post office box) (city) (state) (zip) Person responsible for event: ___________________________ Telephone number: ______________________________ II. EVENT: __________________________________________________ (type of event) Date: ________________________________________________ (month) (day) (year) Hours of event: (beginning) __________ (ending) _____________ Location: _______________________________________________ (actual location) Address: _______________________________________________ (street) Location is _ inside _ (city) (zip) outside the corporate city limits? III. LIST THE PACKAGE STORE OR STORES FROM WHICH THE ALCOHOLIC BEVERAGES USED IN THIS EVENT WILL BE PURCHASED. Business Name: ________________________________________ Address: ______________________________________________ (street) (city) (zip) IV. Has any officer or director of the organization ever been convicted of any of the following: a felony in any state or federal court OR violation of the "Local Option Alcoholic Beverage Control Laws" of the State of Mississippi OR violation of any law relating to alcoholic beverages, beer or light wine? ___________________ If "yes", explain fully: ______________________________________ ____________________________________________________________ ____________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com PERMITTEE CERTIFICATION AND OATH I, _________________________________________ , certify under penalty of perjury that the organization applying for this Temporary Class I Permit is a bona fide nonprofit civic or charitable organization and, as such, does meet the qualifications of Section 67-1-11, 67-1-37, 67-1-51 (2) and (3), 67-1-55, 67-1-57 (excluding paragraph (e)) and 67-1-59. I affirm that this organization, in the exercise of this permit, will comply with the Local Option Alcoholic Beverage Control Laws, Rules and Regulations, relative to the purchase, sale, and handling of alcoholic beverages and will keep all records and make all reports and remittances as required thereby. I certify that the information presented on the application is true and correct, to the best of my knowledge and belief. BY: ________________________________________ TITLE: ______________________________________ DATE: _______________________________________ NOTARY State of Mississippi County of ______________________ THIS DAY, personally came and appeared before me, the undersigned authority in and for the county and state aforesaid, the within named __________________________ , who, after being by me first duly sworn, states on oath that the matters and things contained and set forth in the foregoing application are true and correct. Sworn to and subscribed before me, this the ____ day of __________ , 19___. ____________________________________ Notary Public My commission expires: _____________________ American LegalNet, Inc. www.FormsWorkflow.com