ABCD 1999T1 (REVISED 08/2013) APPLICATION, CLASS 1 TEMPORARY RETAILER'S PERMIT ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS 39130-0540 RETURN TO American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR PROPER FILING OF YOUR APPLICATION PLEASE READ PRIOR TO COMPLETING THIS APPLICATION 1. The application fee is $35.00 and must be in the form of a cashier's check or money order payable to the Alcoholic Beverage Control. This payment must be returned with this completed application. (NOTE: IF THE EVENT IS FOR MORE THAN ONE DAY, THEN THE PAYMENT MUST TOTAL $35.00 PER DAY). 2. 3. 4. The applicant's signature must be notarized by a licensed Notary Public. The alcoholic beverages used by you under this permit must be purchased from a licensed package retailer located in the same county as your event. This application, with fee, must be received by the Alcoholic Beverage Control at least two (2) weeks prior to the event to assure adequate time for the processing and mailing of your permit. CLASS I TEMPORARY PERMITS ARE ISSUED EXCLUSIVELY TO NON-PROFIT CIVIC OR CHARITABLE ORGANIZATIONS. TO VERIFY REGISTRATION WITH THE SECRETARY OF STATE, APPLICANTS MUST ENSURE THAT THE FULL AND CORRECT NAME OF THE ORGANIZATION (AS LISTED WITH THE SECRETARY OF STATE) IS LISTED IN THE "APPLICANT" LINE OF THIS APPLICATION. FAILURE TO DO SO MAY RESULT IN YOUR APPLICATION BEING RETURNED. If you have questions, or need assistance, please call the ABC Permit Department (601) 856-1330. (08/2013) PERMIT DEPT. USE ONLY American LegalNet, Inc. www.FormsWorkFlow.com AMT. OF CHECK CHECK NO. PERMIT NO. APPLICATION AND AFFIDAVIT FOR CLASS 1 TEMPORARY PERMIT I. APPLICANT: Name (Nonprofit civic or charitable organization as listed with Secretary of State) Address: (street or post office box) (city) (state) (zip) Person responsible for event: Telephone Number: (area code) (phone number) II. EVENT: Date: (month) (Type of event) (day) (year) Hours of event: (beginning) Location: (actual location) (ending) Address: Location is __ inside __ outside the corporate city limits? III. (street) (city) (zip) LIST THE PACKAGE STORE(S) FROM WHICH THE ALCOHOLIC BEVERAGES USED IN THIS EVENT WILL BE OBTAINED: 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 the Temporary Class 1 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. I also agree that making a material misrepresentation on this application shall be evidence of a lack of trustworthiness as contemplated by MS Code Ann. Section 67-1-57 and provide a basis for denial on this application. 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_________________,___. Notary Public My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com