PERMIT NEW YORK STATE LIQUOR AUTHORITY APPLICATION FOR SPECIAL ENTERTAINER’S PERMIT (MINOR) CONTENTS • Instructions for completing the application • Application Form DIRECTIONS FOR COMPLETING THE PERMIT APPLICATION • Must be TYPED or PRINTED (in blue or black ink). • Complete application FULLY. • Follow instructions carefully. Completed applications and any supporting information should be mailed to: NEW YORK STATE LIQUOR AUTHORITY PERMIT UNIT 80 S SWAN STREET ALBANY, NY 12210-8002 Agency Website Address: www.abc.state.ny.us SLA FORM: 200-009 (03/25/11) American LegalNet, Inc. www.FormsWorkFlow.com PERMIT -30 The applicant requests a permit to appear as an entertainer on premises licensed to sell alcoholic beverages at retail. Such permit will be valid only for the date or dates shown on the application and subject to the terms and conditions listed below. This application must be properly executed by the applicant and by the parents or guardians of the applicant and filed with the appropriate Zone Office. Any false answer or statement made by the applicant constitutes a misdemeanor and will subject any permit issued hereunder to revocation. APPLICATION FOR SPECIAL ENTERTAINER’S PERMIT (MINOR) Name of applicant:_________________________________________________________________________ Stage name if different:_____________________________________________________________________ Address of applicant:_______________________________________________________________________ City, town or village – zip code:_______________________________________________________________ 1. Name of licensed premises where applicant will perform: ____________________________________________________________________________________ Address of licensed premises:__________________________________________________________ City, Town, Village:__________________________________________________________________ Telephone Number:_______________ County:__________ Serial Number(if known):___________ 2. Day or dates when applicant will perform:_______________________________________________ 3. Applicant’s date of birth:_____________ (If applicant is under sixteen years of age, attach a copy of Child Performers Permit (Sec. 3229 of Education Law). If no permit, submit written explanation. 4. Description of entertainment applicant will perform_______________________________________ Description of entertainment to be offered in licensed premises during applicant’s appearance (Example: dramatic play, dance revue, etc.)______________________________________________ 5. Will parent or legal guardian be present during applicant’s appearance? _____YES _____NO 6. Has applicant ever previously applied for or been granted a Special Entertainer’s Permit? American LegalNet, Inc. www.FormsWorkFlow.com PERMIT _____YES _____NO PARENTS OR GUARDIANS MUST COMPLETE THE FOLLOWING: Date of Application_______________ ______________________________ also known as__________________, age_____, has my (Given name of child) (Stage name, if any) (Years) permission to perform as a ______________________________ on__________________, (Type of Performance(s) ) (Dates) from___________________, at________________________________________________, (Times) (Name of Establishment) located at__________________________________________________________________, (Street Address, City, State, Zip) and I fully intend to be present throughout________________performance. (his/her) ______________________________________ Signature of Parent/Guardian* _________________________________________ Street Address, City, State, Zip ______________________________________ Signature of Parent/Guardian* __________________________________________ Street Address, City, State, Zip *TO BE SIGNED BY BOTH PARENTS OR GUARDIANS, IF APPLICABLE. NOTE: THIS PERMIT SHALL BE VALID ONLY FOR THE DATE OR DATES SPECIFIED IN THIS APPLICATION, AND FOR PERFORMANCE(S) ONLY AT THE LICENSED PREMISES SPECIFIED HEREIN. American LegalNet, Inc. www.FormsWorkFlow.com PERMIT SUBJECT TO THE FOLLOWING TERMS AND CONDITIONS: 1. No permit will be issued unless the written consent of both parents or the lawful guardian or guardians of the minor is obtained. 2. Except for good cause shown, no permit will be issued to any person under the age of sixteen (16) unless such person has been issued a Child Performer’s Permit pursuant to Section 3229 of the Education Law. 3. The permit shall be valid only for the date or dates specified in the application and for performances only at the licensed premises specified in the application. 4. In no event shall a permit be issued for a period exceeding one year. 5. No permit shall be valid for any performance at which a parent or legal guardian of the minor is not present. 6. Any permit may be revoked by the Authority for cause, and shall be revoked without a hearing, promptly upon the written request of the minor’s parents or legal guardian. 7. No permit is required for an appearance by a minor which is otherwise permitted under Section 100 (2-b) of the Alcoholic Beverage Control Law. __________________________________________ (Signature of Applicant) The undersigned certify that they are both parents or lawful guardians of the above named applicant and that they both consent to the above application and the statements and answers therein are true to their knowledge. Dated: ______________________ __________________________________________ Signature of Applicant’s parent or guardian __________________________________________ Signature of Applicant’s parent or guardian Signatures of both parents or guardians are required. If only one parent or guardian has signed the application, please submit explanation. _______Approved ______Disapproved American LegalNet, Inc. www.FormsWorkFlow.com PERMIT Date:____________ Authorized by:___________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com