For Office Use Only Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 www.liq.wa.gov Call 360-664-1600 for questions License No. Date Amount Rec’d Application for Special Occasion License for a Not-for-Profit Society or Organization A Special Occasion License allows a not-for-profit society or organization to sell spirits, beer, and wine by the individual serving for on-premises consumption at a specified event. Applications must be received by the Licensing Division at least 45 days before the event. Fee is $60.00 per day, per location. Make check payable to WSLCB. Mail application, with check to WSLCB, PO Box 43098, Olympia WA 98504-3098. These licenses are limited to 12 single-day events per calendar year. New application 1. 2. Yes Previous License number if known_________ Name of Society or Organization Street Address of Organization 3. 4. No City State Zip Code What is the UBI or Tax ID number for this organization? UBI # TAX ID # Name of contact person within your organization (must be at least 21 years of age): ( Name 5. 6. 7. Title City 10. 11. 12. State Zip Code County Title Phone No. Inside City Limits Yes No Yes No Date Expected number of persons under 21 years to attend event Expected Number of persons to attend Only certified 501 (c) 3 and 501 (c) 6 organizations registered by the IRS may receive donated product from wineries and/or breweries. All other non-profit organizations are restricted to receiving advertising for the event, dispensing equipment, and/or purchased product from a winery, brewery, manufacturer, distributor, or agent only. Are you receiving anything other than advertising services, dispensing equipment, or product from a Yes No manufacturer, distributor, or agent? Do any officers, directors, and/or stockholders of this organization have an interest in a winery, brewery, Yes No manufacturer, importer or distributor of alcohol? Mail license to: Name 13. 14. ) Area Code Is event being held on church or school property, a military facility, or a liquor licensed premises? If yes, official of event location must sign below to authorize the sale of liquor at the event location. Signature 9. Date of Birth Name of this Event Location where event will be held (building, hall, room, etc.): Event Location Address 8. County Mailing Address/Street/PO Box, City, State, Zip Code Email address Fax number Are you requesting permission to auction or sell beer/wine to go? Date(s) of Event Hours: From To ( Yes ) No Type of Event Music Auction Other Community Celebration Beer Garden Outdoor Event All profits from the sale of alcohol will be returned to the non-profit organizations. I certify that the above statement is true and correct. Signature of non-profit representative _______________________________Date_______ LIQ 285-50-7/08 American LegalNet, Inc. www.FormsWorkflow.com