NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Location: 400 EAST TRYON ROAD RALEIGH NC 27610 (919)779-0700 APPROVED REJECTED BY: DATE: AMOUNT FEE PAID: DATE: RECEIVED BY: TEMP. #: MAIL TO ADDRESS ON BACK OF FORM (Do Not Write Above This Line) APPLICATION FOR LIMITED SPECIAL OCCASION PERMIT A. B. C. D. E. Complete the application by printing in ink. Application must be notarized. Fee is $50.00 submitted by certified check, cashier's check or money order made payable to the NC ABC. Submit a copy of the lease/rental agreement or complete "Lease Information Box" on the back of this form. Submit a certified copy of the applicant's Criminal Record. Can be obtained from the Clerk of Court in the county where the applicant resides. F. The completed application must be submitted 14 days prior to the event occurance. I hereby make application for a Limited Special Occasion permit which authorizes me to transport, possess, and serve fortified wine and spirituous liquor to my guests at a reception, party, or other special occasion. The event will be held on the premises of a business with the permission of the owner of the property. Check One: Individual Limited Partnership Partnership Limited Liability Company Date: (in which event takes place) Corporation County: Individual's Full Name: First (no abbreviations) Middle Last Date of Birth: If representing corporation, give corporation name: Trade Name of Location where event held: Location of event: Street/Route Social Security # ____________ (last four digits only) City State Zip Code Special Event: Date Time Event Begins Date Time Event Ends Note: A Limited Special Occasion permit allows the host of a function to furnish liquor and fortified wine to invited guests, free of charge. Guests are not permitted to bring their own liquor. There can be no charge to attend the function. Any money collected constitutes an illegal sale of alcohol, and violators will be subject to criminal prosecution. I have read and agree. Initial here: Type of Event: IF PERMIT IS TO BE MAILED BY COMMISSION, GIVE NAME AND MAILING ADDRESS: NAME: MAILING ADDRESS: American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT INFORMATION Resident Address: Street/Route City State Zip Code Home Telephone #: Daytime Telephone #: ( ( ) ) Fax #: Business Telephone #: ( ) ( ) email address I CERTIFY UNDER OATH OR AFFIRMATION THAT: - I am not the owner or possessor of the premises applied for. - I am not less than 21 years of age. - I have not been convicted of a misdemeanor controlled substance offense or alcoholic beverage offense within the past two years. - I have not been convicted of a felony within the past three years, and if convicted of a felony before then, I have had my citizenship restored. - I have not had an alcoholic beverage permit revoked within the past three years. - I have the written permission of the owner of the property to serve alcoholic beverages. - The information on this application is correct to the best of my knowledge. - I understand that failure to abide by the ABC laws may result in the immediate revocation of my privilege to possess or serve alcohol. Signature of Applicant_________________________________________________ Sworn to and subscribed before me this the Day Month Year My commission expires: Signature of notary or other person qualified by law to administer oaths Lease Information As owner/lessee of the premises, I have no objection to: _____________________________ LSO Applicant receiving a Limited Special Occasion Permit for use on said premises on the date of Day Month Year Owner/Lessee Signature ( ) Business Telephone # Telephone # Date MAIL THIS APPLICATION TO: If sending by U.S. Postal Service (regular mail): If sending by U.S. Postal Service EXPRESS MAIL or by FEDEX/UPS: NC ABC COMMISSION 4307 MAIL SERVICE CENTER RALEIGH NC 27699-4307 NC ABC COMMISSION 400 EAST TRYON ROAD RALEIGH NC 27610 American LegalNet, Inc. www.FormsWorkFlow.com Application for Limited Special Occasion Permit Rev. 10/15