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teryiffe <br /> •r:u.ar,rrd,.•.r�.�•: <br /> CITY OF CENTERVILLE <br /> APPLICATION FOR A 1 TO 4 DAY TEMPORARY/EVENT ON SALE LIQUOR LICENSE <br /> (Organization or location limited to 3 permits in a 12 month period) <br /> Type or Print Information <br /> Name of Organization Date Organized Tax Exempt Number <br /> Obt'Ll'e-h f $}. G ene v-c V'1C r 2-!S7(o Z-O <br /> Street AddressCity State Zip Code <br /> ceVtAe-64 i�e- M I-) I u-�b-S V <br /> Name of Person Completing Application Business Phone Home Phone <br /> Dates�Liquor Will Be Sold(1 to 4 days) Type of Organization <br /> 1�w u0t (1 z,31,I 0 CLUB 0 CHARITABLE' ELIGIOUSD OTHER NON-PROFIT <br /> Or anizati n Officer's Name Address <br /> �, Gr� � s�,LtAe- <br /> Organization fficer's Name Address <br /> Organization Officer's Name Address <br /> Location where license will be used. If an outdoor area,describe: <br /> to t 4 <br /> Will the applicant contract for intoxicating liquor services? If so,give the name and address of the <br /> Liquor license providing the service. <br /> Will the appil nt carry liquor liability insurance? If so, the carrier's name and amount of <br /> Covera e. �' '3u3 (it)c> <br /> APPROVAL <br /> APPLICATION MUST BE APPROVED BY CITY COUNCIL PRIOR TO SUBMISSION TO LIQUOR CONTROL <br /> CITY OF CENTERVILLE DATE APPROVED <br /> FEE AMOUNT LICENSE DATES <br /> DATE FEE PAID <br /> Ci!y Clerk <br /> NOTE: Submit to the City of Centerville.at least thirty(30)days prior to event. <br /> Signature of Applicant: <br /> -5c 00av <br /> 28 <br />