SPECIAL EVENT PERMITS 1. Type of permit requested: Has the applicant applied in the last 12 months for a temporary beer & wine permit? NO YES NO YES If YES, provide date last applied: Is the applicant currently licensed by the State Liquor Authority? If YES, provide License Serial Number: 2. Name of Applicant, Organization or Group: Trade Name (if applicable): Business or mailing address of applicant: City: State: County: Telephone No. (include area code): Zip Code: Has the applicant or (if partnership) any of the partners, or (if a corporation) any of the officers, directors, stockholders, or any agent or employee of the applicant, ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony or of any other crime or offense of any kind except traffic violations? NO YES Previously Reported If YES, submit a Certificate of Disposition or a Certificate of Conviction by the Court Clerk for each case. 3. Nature of event: Date or dates of event: From: To: Day: From: To: Day: From: To: Day: No. of Permits requested (see instructions regarding separate permits for each day, as well as each point of sale): Wiil function be held: INSIDE OUTSIDE Name of place where event is to be held: BOTH Number of Attendees: Street address where event is to be held: City: State: Zip Code: County: Telephone No. (include area code): Is the gathering being held for the benefit of anyone other than the applicant? NO YES NO YES If YES, state name of beneficiary: Will anyone other than the applicant or beneficiary named above share in the receipts from this gathering? If YES, provide details: SLA FORM 1011 (05/03/07) Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com 4. Name of Landlord/Owner of property where the function will take place: Will the function be held on a licensed premises? NO YES Has the premises ever been licensed? NO If YES, state license number: YES I, the landlord/owner of the applied for premises, hereby grant permission for the sale or services of alcoholic beverages by the applicant for consumption on said property. Landlord Signature 5. Title Date PROVIDE A DIAGRAM OF THE AREA TO BE LICENSED ON THE FORM PROVIDED AT THE BACK OF THE APPLICATION. ANSWER THE QUESTIONS BELOW AND INDICATE THESE ITEMS ON THE DIAGRAM. Number of restrooms available: Number of bars or stands serving alcoholic beverages: Area where consumption of alcoholic beverages will be restricted to: Number of entrances/exits to restricted area: 6. Name and address of Police Jurisdiction at event site: Who will provide security for this function: (provide details for security measures on the sheet provided at the back of the application) Will the function be held on a licensed premises? NO YES Has this function been advertised: If YES, provide details: NO YES 7. (Caterers Permits ONLY) PROVIDE THE MENU FOR FOOD AND ALCOHOLIC BEVERAGES TO BE SERVED BY APPLICANT/ LICENSEE ON THE SHEET PROVIDED AT THE BACK OF THE APPLICATION. Name of person, organization, group or association holding the function: Business or mailing address of above: City: State: Zip Code: County: Telephone No. (include area code): 8. (Caterers Permits for club licensees -OFF the club premises ONLY) I certify that I am an authorized officer of the applicant licensee club; that the function to be held will be exclusively for the use and benefit of the club members only and will be so restricted; that the club has not advertized such an affair as open to the public; alcoholic beverages shall be sold only to members attending such function; and that the statements contained in this application are true. Authorized Officer Signature SLA FORM 1011 (05/03/07) Title Page 2 of 7 Date American LegalNet, Inc. www.FormsWorkFlow.com 9. (Caterers Permits for club licensees -ON the club premises ONLY) The Alcoholic Beverage Control Law provides that a Caterer's Permit may be issued to a licensed club to cater an affair to be held on the club premises if at least one of the following is applicable (check all that apply): The particular function or event is to be held by the sodality, auxiliary or other organization affiliated with the licensed club (state which): A particular charitable or non-profit function or event is to be held by the organization which is a charitable or non-profit organization and such organization has one or more members who are also members of the club (state names): The function or event is in conjunction with the use of the primary athletic or sports facilities of the licensed club and is to be held by the non-affiliated organization (state name of primary athletic or sports facilities): The function or event is being held on the clubpremises because no other suitable licensed premises authorizes to sell alcoholic beverages to the public is available within a reasonable distance (set forth the facts to establish foregoing): (Use additional sheets if necessary.) I certify that I am an authorized officer of the applicant licensee club; that the club has not solicited the function, nor advertised such function in any manner as open to the public and alcholic beverage shall be sold only to persons invited to and attending such function, occasion or event; and that the statements contained in this application are true. Authorized Officer Signature SLA FORM 1011 (05/03/07) Title Page 3 of 7 Date American LegalNet, Inc. www.FormsWorkFlow.com 10. (Certification to be completed by ALL applicants) This certification must be signed and dated by: the individual applicant OR each member of a partnership OR an officer duly authorized by order of the Board of Directors of the applicant corporation, group or association to make the statements and answers in this application on behalf of said applicant entity, with the same force and effect as if said entity made such statements and answers itself. I certify that I know the contents of this application and the statements contained therein; that the same are true of my own knowledge; and that I am authorized to execute this application and sign this certification. I further certify that I have read the terms and conditions for the applied for permit and agree to comply with those conditions. Authorized Signature Title Date Authorized Signature Title Date Authorized Signature Title Date PROVIDE THE FOLLOWING FOR ALL AUTHORIZED SIGNATURES ABOVE (attach additional sheets if necessary): Print Name: Date of Birth: Age: Residence street address of above: City State: County: Telephone No. (include area code): Zip Code: Print Name: Date of Birth: Age: Residence street address of above: City State: County: Telephone No. (include area code): Zip Code: Print Name: Date of Birth: Age: Residence street address of above: City State: County: Telephone No. (include area code): Zip Code: [OFFICE USE ONLY] Approved Disapproved Amount Rec'd Deposit Date Audited by Batch SLA FORM 1011 (05/03/07) Page 4 of 7 Item American LegalNet, Inc. www.FormsWorkFlow.com DIAGRAM OF AREA OF CONSUMPTION Please indicate location of all points of sale, restrooms and all entrances/exits on this diagram. SLA FORM 1011 (05/03/07) Page 5 of 7 American LegalNet, Inc. www.FormsWorkFlow.com MENU Please list below all food and beverage items being served at the event: SLA FORM 1011 (05/03/07) Page 6 of 7 American LegalNet, Inc. www.FormsWorkFlow.com SECURITY STATEMENT Please provide details below as to the security measures in place for this event: SLA FORM 1011 (05/03/07) Page 7 of 7 American LegalNet, Inc. www.FormsWorkFlow.com