PLCB-1986 1/06 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPLICATION BY CLUB LICENSEE FOR EXTENDED HOURS FOOD PERMIT BUREAU OF LICENSING (SEE INSTRUCTIONS ON REVERSE) The undersigned hereby applies for a permit to sell food as permitted under the said license between the hours of three o’clock a.m. and seven o’clock a.m., of any day, in those rooms in the establishment habitually used for the serving of liquor or malt or brewed beverages. This application is made for the license period expiring _____________ , 20 ____ , for: 1. Mo./Date/Year Mo./Date/Year _____ / _____ / _____ Mo./Date/Year Mo./Date/Year Mo./Date/Year Mo./Date/Year _____ / _____ / _____ _____ / _____ / _____ _____ / _____ / _____ _____ / _____ / _____ 2. CONTACT PERSON _____ / _____ / _____ DAYTIME PHONE NO. ( 3. NAME OF LICENSEE LID NO. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) 4. ) LIC NO. (POST OFFICE) (STATE) (ZIP) RESOLUTION At a regular or special meeting held on ______________________________ , 20 ______ by the applicant club, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that ______________________________________ and/or ____________________________________ is/are hereby (NAME OF OFFICER/TITLE) (NAME OF OFFICER/TITLE) authorized to execute said application, and any other papers required by the Board. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE SIGNATURE TITLE HOME ADDRESS PHONE HOME ADDRESS PHONE ( ) ( ) DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS This form is to be used by club licensees to apply for an Extended Hours Food Permit solely for the purpose of serving food between the hours of 3:00 a.m. and 7:00 a.m. 1. Print or type all information required. All questions must be answered, even if the answer is ‘NONE’ or ‘NOT APPLICABLE.’ This form MUST be signed. 2. A fee of $50.00 must accompany this application. Make remittance payable to “PLCB” or “Commonwealth of Pennsylvania.” INFORMATION Extended Hours Food Permits issued to clubs for up to six (6) days during a license period. All patrons of the club shall be required to leave that part of the premises habitually used for the serving of liquor and malt or brewed beverages to guests or patrons not later than 3:30 a.m., and shall not be permitted to have any previously served liquor or malt or brewed beverages in their possession, nor shall they be permitted to remove any previously served liquor or malt or brewed beverages from that part of the premises. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250, OPTION #7. SEND THE APPLICATION PACKET TO: PENNSYLVANIA LIQUOR CONTROL BOARD, BUREAU OF LICENSING, P.O. BOX 8940, HARRISBURG, PA 17105-8940. American LegalNet, Inc. www.FormsWorkflow.com