Plcb-2403 10/12 coMMonwealTh of PennsYlvania PennsYlvania liquor conTrol boarD APPLICATION FOR OFF-PREMISES CATERING PERMIT bureau of licensing The undersigned hereby applies for an off-Pemise catering Permit for calendar year 1. name of licensee 2. Trade name (if any) 3. address of Premises retail license no. liD no. (Street, Rural Route, PO Box No.) (Post Office) (State) (Zip) 4. is there a catered function scheduled at this time? no Yes if no, submit this application prior to March 1st with fee. if yes, submit this application and a 2403a "application for off-Premises catered function" for each function scheduled. RESOLUTION at a regular or special meeting held on it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that Name of Officer/Title by the applicant, and/or Name of Officer/Title is/are hereby authorized to execute said application, and any other papers required by the Board. I swear and affirm, subject to the penalties provided by 18 Pa. C. S. §4904 and 47 P. S. §4-403(h) that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. Signature Home Address Signature Home Address E-mail Address Title Phone Title Phone Date Signed Name of Attorney representing you in this matter if any Address Phone INSTRUCTIONS This form is to be used to apply for an Off-Premises Catering Permit. It must be filed along with a fee of $500.00 by March 1st of each calendar year, regardless of whether any functions are planned. The fee is non-refundable. DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkFlow.com