OHIO DEPARTMENT OF COMMERCE, DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD REYNOLDSBURG, OHIO 43068-9005 Telephone No. (614) 387-7407 Fax No. (614) 644-6965 http://www.com.ohio.gov/liqr F PERMIT APPLICATION FILING FEE $40.00 Five-Day Privilege for Special Functions - Valid for the Sale of BEER ONLY, Until 1:00 a.m. APPLICATION MUST BE FILED AT LEAST THIRTY (30) DAYS PRIOR TO THE DATE OF FUNCTION § 4303.20 F permit. Permit F may be issued to an association of ten or more persons, a labor union, or a charitable organization, or to an employer of ten or more persons sponsoring a function for the employer's employees, to purchase from the holders of A-1 and B-1 permits and to sell beer for a period lasting not to exceed five days. No more than two such permits may be issued to the same applicant in any thirty-day period. The special function for which the permit is issued shall include a social, recreational, benevolent, charitable, fraternal, political, patriotic, or athletic purpose but shall not include any function the proceeds of which are for the profit or gain of any individual. The fee for this permit is forty dollars. CAREFULLY READ THE GENERAL INSTRUCTIONS FOR FILING AN F APPLICATION - ON PAGE 5 TYPE OR PRINT PLAINLY ALL QUESTIONS MUST BE ANSWERED Name of Non-Profit Organization (Exact Name must be uniform on all documents - please do not abbreviate) Street Address (Where Function Will Be Held - BE SPECIFIC & must be uniform on all documents - For Street Closures see Address Addendum -Page 1(A) Township (Only if outside city or village limits) Mail and/or Fax Permit and Correspondence To: Street Address: Phone #: City Name: City: Fax #: State OHIO Zip Code County: State: Zip Code: Email Address: Individual responsible for the compliance with Ohio's liquor laws in conjunction with the sale and consumption of alcoholic beverages: Date and Time Function Will Begin: Date and Time Function Will End: (Note: This is for notification purpose only - NOT for emailing correspendence) Name: Phone #: Title: Date Function Begins: (Month/ Day/ Year) Date Function Ends: (Month/ Day/ Year) Time Function Begins: am am pm pm Time Function Ends: Please check what type of organization: Association of ten or more persons Charitable Organization Employer of ten or more persons sponsoring a function for his employees, except for a manufacturer or wholesale distributor of alcoholic beverages (not open to the public) Labor Union The Division of Liquor Control does not regulate or advise individuals regarding gambling in conjunction with the issuance of an F permit. Any question regarding gambling should be directed to the Ohio Attorney General's Office, Charitable Gaming Section, 150 East Gay Street, 23rd Floor, Columbus, OH 43215 at (614) 466-3181. FOR OFFICE USE ONLY Taxing District Permit Number Receipt # Remarks: Reviewer Action: DLC 4115 Rev. 10/8/2013 American LegalNet, Inc. www.FormsWorkFlow.com ADDRESS ADDENDUM This Addendum is to be used if there will be any type of street, alley, or public sidewalk closure. Additionally, please attach an acknowledgement from the legislative or local police authority in control authorizing the closure. If the premise covers an area that includes adjacent streets, alleys, or public sidewalks that will be closed, please list and identify the street name and address/street range (i.e., Main Street - From 600 Block To 700 Block) NOTE: Include a copy of this form to both the Chief Peace Officer and Real Property Owner listed in Sections A & B on Page 3 of this application. STREET NAME ADDRESS or STREET RANGE FROM TO DLC 4115 Page 1(A) American LegalNet, Inc. www.FormsWorkFlow.com 1. What is the purpose of the event? (NOTE: The proceeds of the function shall not be used for the profit or gain of any individuals). 2. Will 100% of the proceeds, less expenses, from the applicant's sale of alcoholic beverages either be retained by the applicant or distributed by the applicant for non-profit social, recreational, benevolent, charitable, fraternal, political, patriotic or or athletic purposes? If "NO", please give detailed explanation: YES NO 3. Will any individual or for profit association, corporation, or other legal entity receive any percentage of the proceeds after expenses from the event for which you are requesting the F permit? If "YES", please explain, identifying share of profit or gain each person/party will receive: YES NO 4. Will the members of the applicant organization coordinate and operate the event and conduct the sale of alcoholic beverages? If "NO", please submit a detailed explanation of the non member involvement and their financial compensation. YES NO 5. Give the name and address of the brewer or distributor from whom beer will be purchased. _____________________________________________________________________________________________ _____________________________________________________________________________________________ The Division of Liquor Control does not regulate or advise individuals regarding gambling in conjunction with the issuance of an F permit. Any question regarding gambling should be directed to the Ohio Attorney General's Office, Charitable Gaming Section, 150 East Gay Street, 23rd Floor, Columbus, OH 43215 at (614) 466-3181. THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT(S): STATE OF OHIO, __________________________________COUNTY, ss I/We _________________________________________________________being first duly sworn, according to law, depose and say that the statements and answers made in the foregoing application are true, and say that I/We are at least twenty-one years of age and the statements and answers made in the foregoing application are true. I hereby acknowledge that I/We are required by law to be responsible for any conduct that violates laws pertaining to the sale of alcoholic beverages. FALSIFICATION OF ANY OF THE INFORMATION ON THIS APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO ISSUE THIS PERMIT AND WILL BE PUNISHABLE TO THE FULLEST EXTENT OF THE LAW _____________________________________________________ _____________________ (Signatures of Officer of Association, Lodge or Corporation) (Title) __________________________________________ (Print Name) ________________________________________________ ___________________________ _______ _________________ _____________________________ (Residence Address) (City) (State) (Zip Code) (Telephone Number) (This portion to be completed by Notary Public) Sworn to