APPLICATION FOR ALCOHOLIC LIQUOR LICENSE Date: TO THE LIQUOR AND GAMING L I C E N S I N G BOARD OF CLARK COUNTY: The undersigned hereby applies for a license or licenses and if granted will accept same subject to all terms, regulations and provisions of the Ordinance or Regulation under which it is granted. Please type or print all information. If more space is required for any item, use attached continuation sheet. NAME OF APPLICANT (OPERATING ENTITY) BUSINESS ADDRESS (Number, Street & Zip) MAILING ADDRESS NAME & ADDRESS OF PROPERTY OWNER DBA BUSINESS NAME (As it should appear on the license) BUSINESS TELEPHONE Partnership Individual 1. Type of Organization: Corporation LCC Other 2. If other than a Sole Proprietor, l is t each o w n e r / officer and percentage applied for. If a Sole Proprietor, complete all items: Zip Code US Citizen Yes No Name & Title Address Telephone % Number & Type of License Applied For Quarterly Fee Number & Type of License Applied For Quarterly Fee Main Bar (Resort Hotel)...............................$525.00 Tavern .................................................... $300.00 Service Bar..............................................$300.00 Package Liquor......................................... $450.00 (If with Tavern)........................................ $150.00 Package Beer. ............................................$125.00 Individual Access..... ...............................$1,000.00 Portable Bar..............................................$300.00 Package Beer, Wine & Spirit Based Products.........175.00 Retail Beer................................................$100.00 Retail Beer & Wine......................................$150.00 Brewery .................................................$250.00 TOTAL LICENSE FEES PAID WITH THIS APPLICATION: $ Import-Wholesale....................................................$650.00 Non-Profit Club.......................................................$200.00 Supper Club.............................................................$300.00 Sports Facility.........................................................$ Full Bar ...................................................................$300.00 Liquor Caterer..........................................................$200.00 Public Facility (Per Bar)........................................ $300.00 Keg Beer Delivery...................................................$350.00 Brew Pub.................................................................$300.00 Wine/Cordial Tasting..............................................$300.00 Master Liquor .........................................................$ Filing Fee..................................................$ 50.00 INVESTIGATION FEES PAID: $ I hereby acknowledge and promise to pay all investigation fees in an amount equal to the actual cost incurred by the County to complete the necessary investigation, and understand that this is due and payable prior to the Liquor and Gaming Licensing Board taking final action on my application. SIGNATURE BL-46-76 (Rev. 05/31/2013) TYPED OR PRINTED NAME OF APPLICANT- TITLE American LegalNet, Inc. www.FormsWorkFlow.com