Ohio Department of Commerce - Division of Liquor Control 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 Telephone No. (614) 387-7407 - http://www.com.ohio.gov/liqr F-4 PERMIT APPLICATION An F-4 permit may be issued to an association or corporation organized not-for-profit in this state to conduct an event that includes the introduction, showcasing, or promotion of Ohio wines. An F-4 permit allows the association or corporation to furnish at no charge, 2 oz. samples and to sell by the glass, for on premises consumption, wine provided by at least three A2 permit holders who sell Ohio wine. The participating A2 permit holders may sell wine that they have manufactured, in sealed containers for consumption off the premises, until 1 AM for a period not to exceed three days. APPLICATION MUST BE FILED 30 DAYS PRIOR TO EVENT THE FEE FOR AN F-4 PERMIT IS $60.00 PER DAY SECTION (A) Name of Association or Corporation: PROPOSED F-4 PERMIT PREMISES INFORMATION Name of Event: Event Street Address: Township (if outside city limits): Mail and/or Fax Permit and Correspondence To: Name: State: Zip Code: Street Address: Phone #: Name: Title: Fax #: City: City: Zip Code: County: Individual responsible for the compliance with Ohio's liquor laws in conjunction with the sale and consumption of alcoholic beverages: Date and Time Date Function Begins: Function Will Begin: Date and Time Function Will End: Time Function Begins: am pm Date Function Ends: Time Function Ends: am pm SECTION (B) APPLICANT/ORGANIZATION'S INFORMATION 1. List the Organization's non-profit Charter/Registration number from the Ohio Secretary of State's office 2. Please provide the Top Four Officers of the Organization: Name: Residence Address: Phone: Name: Residence Address: Phone: Title: Title: Name: Residence Address: Phone: Name: Residence Address: Phone: FOR OFFICE USE ONLY Taxing District Permit Number Receipt # Title: Title: Reviewer Action: Remarks: DLC4200 Page 1 Rev. 9-21-12 American LegalNet, Inc. www.FormsWorkFlow.com SECTION (C) ORGANIZATION INFORMATION 1. Is the event coordinated by your association or corporation? 2. Will your association or corporation be responsible for the activities at the event? 3. Is your intent to introduce, showcase, or promote Ohio wines to persons who attend the event? 4. Provide the name, address and permit number of at least three A2 permit holders participating in the event (use additional sheet if necessary) Address: 1) Name: City, State, & Zip: Address: 2) Name: City, State, & Zip: Address: 3) Name: City, State, & Zip: SECTION (D) - Applicant's Signature & Notarization: State of Ohio, I, (Please Print) YES YES YES NO NO NO Permit # Permit # Permit # County, ss being first duly sworn, according to law, depose and say that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) _____________________ (Title) _______________ (Date) (Residence Address) (To be completed by Notary Public) (City) (State) (Zip Code) (Area Code & Telephone Number) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) _______________ (Notary Expiration) TO ENSURE THAT THIS APPLICATION IS PROCESSED AS QUICKLY AS POSSIBLE, PLEASE SUBMIT THE FOLLOWING, ALONG WITH THIS COMPLETED, SIGNED, AND NOTARIZED APPLICATION $60.00 Permit Fee per each day of the event Completed & signed Consent Form Completed and signed "Diagram of Permit Premises for F-4 Liquor Permit" form and any attachments. Explanation of any officer's conviction for any felony or misdemeanor, if applicable. Current Certificate of Good Standing from the Ohio Secretary of State's Office indicating the organization's Not-for-Profit status. You must provide on this application, under Section C at least three A2 permit holders that will participate in this event. EOE/ADA SERVICE PROVIDER Page 2 FOR TTY USERS DIAL ORS 1-800-750-0750 American LegalNet, Inc. www.FormsWorkFlow.com OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 CONSENT TO / NOTIFICATION OF F-4 LIQUOR PERMIT Section F. (Completed by Applicant): TEMPORARY PERMIT FUNCTION INFORMATION The ________________________________________________________________________________________________________________ (Full Name of Organization [this must be same as what is listed on Application]) will be conducting an event at the location of ________________________________________________________________________________ (Location or Street address where function held [this must be same as what is listed on Application) and has applied for an "F-4" class temporary liquor permit to allow 2 oz. samples and sale of wine: beginning _____________________________________ (Date Function Begins) at (Time Function Begins) am pm and ending ____________________________________ (Date Function Ends) at __________________ (Time Function Ends) am pm Section G. (Completed by Property Owner): CONSENT OF REAL PROPERTY OWNER INFORMATION If applicant is owner of real property mark box, and sign below. I/We, being the owner of the realty located at the address mentioned in Section A. above, do hereby acknowledge notification that the Organization listed above will hold a special function on the dates specified by signing below. X____________________________________________________________ _________________________________________________ _________________ (Print Name of Real Property Owner) (Date) (Signed - Real Property Owner) _______________________________________________________________________________________________________________________________ (Telephone Number) (City, State, and Zip Code (Street Address of Real Property Owner) Section C. (Completed by Chief Peace Officer): NOTICE TO CHIEF PEACE OFFICER (City/Township Police, OR County Sheriff) This portion must be signed by the Chief Peace Officer in the municipality or the township where this function will be held indicating that he/she has been notified of the date, time, place and duration of the event. (If the township does not have a Chief Peace Officer, the County Sheriff's Office must be notified accordingly.) I, being the Chief Peace Officer of the City, Township or