NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Location: 400 EAST TRYON ROAD RALEIGH NC 27610 (919)779-0700 abc.nc.gov AMOUNT FEE PAID: DATE: RECEIVED BY: TEMP. #: APPROVED REJECTED BY: DATE: (Do Not Write Above This Line) SPECIAL ONE-TIME PERMIT APPLICATION FOR SALE OF ALCOHOLIC BEVERAGES Application Instructions: A. B. C. D. Complete this application in its entirety. (Please print.) Applicant's signature must be notarized. The fee for a Special One-Time permit is $50.00. The fee must be submitted by certified check, cashier's check, or money order, and made payable to the North Carolina Alcoholic Beverage Control Commission. E. The permittee shall notify local law enforcement and have the notification signed by law enforcement. (On back of form.) F. The completed application must be submitted 14 days prior to event occurrence. I hereby make application to the North Carolina Alcoholic Beverage Control Commission for a Special One-Time permit allowing the sale or service of alcoholic beverages at the event described below: Please check applicable box(es): I (We) are a : Nonprofit or at a ticketed event the following: Political Organization, requesting authorization to Malt beverages Wine Sell or Serve Spirituous Liquor Permit brownbagging The following documents are required: 1. Lease or rental agreement between nonprofit organization and owner of the premises. 2. Diagram of the actual premises showing all entrances, exits, bar areas, and where consumption and/or sale will take place. 3. Documentation to show that the organization is exempt from taxation under the appropriate subsection of Section 501(c) of the Internal Revenue Code or is exempt under similar provisions of Chapter 105 of the North Carolina General Statutes. 4. Purpose of fund-raiser and recipient of funds raised. 5. Certified copy of criminal record check must be submitted for individual applying for a special one-time permit. 6. A political party as defined in NC General Statute 163-96(a)(1) or (2) or a campaign organization which has properly filed and has had a person certified as a candidate . Statute 163-1. NAME OF ORGANIZATION OR CANDIDATE: LOCATION: Where event or transaction will take place Name of Building: (if applicable) Address: COUNTY: ______________________ If event is being held inside the city limits, indicate city: ( In which event is to be held) MAILING ADDRESS FOR PERMIT: DATE(s) OF EVENT: Estimated Attendance TIME OF EVENT: Ending Beginning American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL INFORMATION OF INDIVIDUAL REPRESENTING THE ORGANIZATION OR CANDIDATE: First (no abbreviations) Middle Last Date of Birth Applicant's Home Address ( City ) ( State ) ( Business Telephone # Home Telephone # Zip Code ) FAX # NOTIFICATION TO LOCAL LAW ENFORCEMENT: To be completed by an officer of the Sheriff's Office, if event is held in the County, or completed by an officer of the Police Department, if event is held in the City. Name of Officer Signature of Officer ( ) Department of Officer Telephone # Comments It is a Crime to make a false statement to obtain an ABC Permit I CERTIFY UNDER OATH OR AFFIRMATION THAT: - 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. - All of the information supplied by me in this application is complete and accurate. - I understand that ABC law prohibits any type of gambling activities or equipment upon my licensed premises (even if not for profit). - I, or my agent, will personally supervise the sale of alcoholic beverages and abide by all ABC laws. - I understand that failure to abide by the ABC laws may result in the immediate revocation of my privilege to sell/serve alcohol. Signature of Applicant Sworn to and subscribed before me this the Day Month Year My commission expires: Notary or other person qualified by law to administer oaths 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 ATTN: PERMIT & PRODUCT COMPLIANCE 4307 MAIL SERVICE CENTER RALEIGH, NC 27699-4307 NC ABC COMMISSION ATTN: PERMIT & PRODUCT COMPLIANCE 400 EAST TRYON ROAD RALEIGH, NC 27610 Special One Time Permit Application for Sale of Alcoholic Beverages Rev 11/2010 American LegalNet, Inc. www.FormsWorkFlow.com