MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL APPLICATION FOR ANNUAL CATERERS PERMIT LEGAL NAME OF ENTITY DOING BUSINESS AS PHYSICAL LOCATION ADDRESS OR LOCATION OF ENTITY'S PRINCIPAL OFFICE (STREET ADDRESS) CITY, STATE, ZIP CODE MAILING ADDRESS (IF DIFFERENT FROM ABOVE) BUSINESS TELEPHONE NO $500 Annual Caterers Permit (Effective For a Maximum of Fifty Days During Fiscal Year) $1,000 Annual Caterers Permit (Effective For an Unlimited Number of Days During Fiscal Year) The undersigned (individual) (partnership) (corporation) (limited liability company) hereby makes application to the Supervisor of Alcohol and Tobacco Control of the State of Missouri for an annual caterers permit pursuant to Section 311.486, RSMo. Applicant agrees that if the permit herein applied for is granted, and the caterer shall violate any law of the State of Missouri and particularly any provision of the Liquor Control Law and amendments thereto or any Rule or Regulation of the Supervisor of Alcohol and Tobacco Control or permit any other person to do so upon the premises, the Supervisor may suspend, revoke, fine, or take other disciplinary action against the caterer's retail by drink license. Applicant also agrees that he/she will report the location of each function three business days in advance to the Supervisor pursuant to Section 311.486.3 RSMo, and will permit the Supervisor and his agents and inspectors at all times to inspect the premises and every part of the building and plot of ground under his/her control and upon which the reported premises are located, and any place where applicant may have intoxicating liquor stored. Applicant further agrees that this caterers permit will not be used on any premise within 100 feet of the nearest school, church or other building used as a place of religious worship. SIGNATURE OF OWNER, MANAGING OFFICER, OR PARTNER DATE SIGNATURE OF PARTNER (IF THERE ARE MORE THAN ONE) DATE SIGNATURE OF PARTNER (IF THERE ARE MORE THAN ONE) DATE SIGNATURE OF PARTNER (IF THERE ARE MORE THAN ONE) DATE NOTARY INFORMATION NOTARY PUBLIC EMBOSSER OR STATE OF COUNTY (OR CITY OF ST. LOUIS) BLACK INK RUBBER STAMP SUBSCRIBED AND SWORN BEFORE ME, THIS DAY OF NOTARY PUBLIC SIGNATURE YEAR MY COMMISSION USE RUBBER STAMP IN CLEAR AREA BELOW. EXPIRES NOTARY PUBLIC NAME (TYPED OR PRINTED) FOR OFFICE USE ONLY - DO NOT WRITE IN AREA BELOW Based on the information contained herein, the undersigned forward this application for consideration by the Supervisor of Alcohol and Tobacco Control and hereby recommend that this application be approved and the license issued. AGENT DISTRICT SUPERVISOR STATE SUPERVISOR American LegalNet, Inc. www.FormsWorkFlow.com