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<br />MD5m Lions Club Liability QuestionnMre <br /> <br />The Liquor Liability Policy for your Club is coming up for renewal on iune30, 2009 <br />Please complete this form and return it with your check payable to The Hendrickson <br />Agency, Inc. and a copy of the enclosed invoice by June 30,-2009-- <br /> <br />Name of Lions Club~ ",~,,^-,''"T'i2-VI<-L1< l-\(;I.,J~ t:.-\..-v~ <br /> <br />Mailing Address: <br /> <br />']1 r;-l;> j;'j2\,.)-ol ~\v.= <br />L.......--re?-\l,~ r ""oJ '7Cit:i3~ <br /> <br />Location address for meetings: '? 0 'Z-t- L..-,,""\~ ,....or ~""'7 <br /> <br />~,J\~l\.l...li"" ,~ <br />, <br /> <br />Estimate Annual Gross Receipts/Side of Alcohol: ~ ~ t:t;>c> - <br />, <br /> <br />'7'70'?f> <br />~ 10, &>t':>P <br />, <br /> <br />. <br /> <br />Estimate number of events during one year: , -? <br /> <br />Name, address and phone number of contact person in your Club: <br /> <br />~".t.- lL-1...~ Phone: b.t~ - 2+-' -912-2- <br />~ ~I"'-' ~'II" - <br />sr-~,~ oW s;q..'?>t's <br /> <br />Please list below name and address of any cities or etc. to Whom you need certificate of <br />your Liquor Liability sent. <br />?-rr""'f bi':Z t..<<-..;j6l?1-\}\~ <br />\ e~ iI'^~t,....l ~"..-. <br />~~It-l-(f~ ~~3e. <br />1-'>11 r-'" ~~A _J;-lsi2- <br /> <br />1-1...11".> lA\k? L-I-ry HA4.-- <br />bt:x> -TOW+-! ~~ Wwy <br />L~t>~~7 ~ qSo /4 <br />A<rn : ({' ~L- <br /> <br />If more are needed, attach a separate list. If you have a copy oflast years' certificate that <br />was issued, please send me a COpy. <br /> <br />If you have any questions, call me at 952-934-1762 or f8x 952-944-0607. <br />Return this application and your check to: Burdell R. Wasels, PDG <br />MD91lnsurauce COllsultant <br />13214 Kerry Lane <br />Eden Prairie, MN 5!346 <br /> <br />Make your cheek payable to: The Hendriekson Ag_y, 1Ile. <br /> <br />38 <br />