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<br />MDSm Lions Club Liquor Liability Questionnaire <br /> <br />The Liquor Liability Policy for your Club is coming up for renewal on June 30, 2006. <br /> <br />Please complete this fonn and return it with your check and a copy of the enclosed <br />invoice by June 30, 2006.. <br /> <br />Name of Lions Club ~...J-r1ri2-vi~ L-lb~~ ~ua.- <br /> <br />Mailing Address '7 I?? E:i2-'A~ ~l \I~ <br />~._;'\-~~,,<,-~l!" I tvo...J '?~o3S <br /> <br />Location address for meetings / D ~ {, 'L-a-\...1"I-,; i:2-VII.."-",,g- ;2-CAY> <br />';:::"o~?-J u- -.....:r ",^_i ~ ~D :? J?, <br />. <br /> <br />Estimate Annual Gross Receipts/ Sale of Alcohol <br /> <br />$0 7. I?r:>t> - ~ 1'7. bO~ <br />. . <br /> <br />Estimate number of events during one year \ - ft <br /> <br />~ame, address and phone number of contact person in your Club. <br /> <br />b~b- ~~~I!f,-t""!I-~ <br />/t~5 -a,~~ ~1i.E <br />4~~~;~. t-J ';;:::;.o~ <br /> <br />Phone bG! r Y; 3>- i~ <br />ht ~.. :t-";U - q,7---2- <br /> <br />Please list below name and address of any cities or etc. to whom you need a certificate of <br />your Liquor Liability sent. <br />?,-rt ,...,p .c..a...rr~~ ll;,-~ <br />I e ~o \I"A"A ,...j ~e'I <br />~~~I~. .......J c.:1~o;3e <br />~...J: ~~~A 't3C;,...lDEj2... <br /> <br />\-11roJ p ~ .?-l'f'( HIAl-l- <br />hOT:;;> """\'~ ~tj€;4 t:>~f <br />\.-\ _I::> \-Au->. M.,.J '37':>'~ <br />i"\1'rH" ->Vv1li t3Ai2--'/e\..ol- <br /> <br />If more are needed, attach a separate list. If you have a copy of last years certificate that <br />was issued. please send me a copy. <br /> <br />If you have any questions call me at 952/934.1162 or fax 952/944-0607. <br />Return this application and your check to: Burdell R. Wessels, PDG <br />MD5M Insurance Consultant <br />13214 Kerry Lane <br />Eden Prairie MN 55346 <br /> <br />Make your check payable to: The Hendrickson Agency Inc. <br /> <br />13 <br />