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i <br /> r teryiffe <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 /> cturchl7v Si. CMe Jt-- 25 L 2a <br /> Street Address CityState Zip Code <br /> 70TI (cwAbn Cd (Zrrkr , rA 5n3g <br /> Nam of Person Completing Application Business Phone Home Phone <br /> ��tsi,a.�".f--Ibtc� <br /> DatAt&AUsf- <br /> Liquor Will Be Sold(1 to 4 days) Type of Organization <br /> I(.0,ZO)S ❑ CLUB ❑ CHARITABLE JIf-RELIGIOUS❑OTHER NON-PROFIT <br /> Organization Officer's Name Address <br /> re 7091 Gold lrv1.I�2 <br /> Organization fficer's Name Address <br /> Organization Officer's Name Address ja w� Ac M <br /> Location where license will be used. If an outdoor area, describe: <br /> lYlw'1 >'1'l <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 appli nt carry liquor liability insurance? If so, the carrier's name and amount of <br /> coverage. n0Ooo <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 /> City Clerk <br /> NOTE: Submit to the City of Centerville at least thirty(30) days prior to event. <br /> Signature of Applicant: <br /> 0",/C WaivAk <br /> 18 <br />