MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL APPLICATION FOR TEMPORARY CATERER'S PERMIT TYPE OR USE ONLY BLACK INK TO COMPLETE THIS APPLICATION LEGAL NAME OF ENTITY DOING BUSINESS AS PHYSICAL LOCATION ADDRESS OR LOCATION OF ENTITY'S PRINCIPAL OFFICE (STREET ADDRESS) CITY, STATE, ZIP CODE BUSINESS TELEPHONE NUMBER MAILING ADDRESS (IF DIFFERENT FROM ABOVE) 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 a temporary caterer's permit to furnish provisions and service for use at a particular function, occasion or event at a particular location other than the licensed premises during the period beginning A.M. P.M. (month, day, year) (starting time) and the period ending A.M. (month, day, year) Said premises are worship. P.M. (ending time) feet from the nearest school, church or other building regularly used as a place of religious I understand that all provisions of the Liquor Control Law, Rules and Regulations of the Supervisor, and ordinances of the incorporated city or the unincorporated area of the county shall extend to such premises and shall be in force and enforceable during the time the permittee or its agent, servants, employees or stock are on such premises. Applicant further agrees that inspections may be made at all times by the Supervisor of Alcohol and Tobacco Control and his agents in accordance with Regulation 70-2.140, Rules and Regulations of the Supervisor of Alcohol and Tobacco Control. SIGNATURE OF MANAGING OFFICER, OWNER OR PARTNER DATE SIGNATURE OF PARTNER DATE SIGNATURE OF PARTNER DATE SIGNATURE OF PARTNER DATE 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