Sla Form 1011 – Fill Out and Use This PDF

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SPECIAL EVENT PERMITS

1.

Type of permit requested:

Has the applicant applied in the last 12 months for a temporary	NO	If yes, provide details:
beer & wine permit?
	YES
Is the applicant currently licensed by the State Liquor Authority?	NO	If yes, provide details:
	YES

2.

Name of Applicant, Organization or Group:

Trade Name (if applicable):

Has the applicant or (if partnership) any of the partners, or (if a corporation) any of the officers, directors, stockholders, or any

agent or employee of the applicant, ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony or
of any other crime or offense of any kind except traffic violations?	NO
	YES	Previously Reported

If YES, submit a Certificate of Disposition or a Certificate of Conviction by the Court Clerk for each case.

3.

Nature of event:		Day of week to be held:
Date or dates of event:			A.M.		A.M.
		FROM:		TO:
			P.M.		P.M.
Number of permits requested:	(see instructions regarding separate permits for each day, as well as each point of sale)
Will function be held:	INSIDE	OUTSIDE			BOTH
Name of place where event is to be held:		Number of Attendees:

Is the gathering being held for the benefit of anyone	NO	If yes, state name of beneficiary:
other than the applicant?
	YES
Will anyone other than the applicant or the beneficiary	NO	If yes, provide details:
named above share in the receipts from this gathering ?
	YES
SLA FORM 1011 (01/29/04)

4.

Name of Landlord/Owner of property where function will take place:

I, the landlord/owner of the applied for premises, hereby grant permission for the sale or service of alcoholic beverages by the applicant for consumption on said property.

Landlord Signature

Title

Date

5.

ATTACH A DIAGRAM OF THE AREA TO BE LICENSED. ANSWER THE QUESTIONS BELOW AND INDICATE THESE ITEMS ON THE DIAGRAM.

Number of bars or stands serving alcoholic beverages:	Number of restrooms available:
Area where consumption of alcoholic beverages will be restricted to:		Number of entrances/exits to restricted area:

6.
Name and address of Police Jurisdiction at event site:
Who will provide security for this function: (submit detailed security	Will this function be open to the public?	NO
statement).
		YES

7.	(Caterers Permits ONLY)

ATTACH A MENU FOR FOOD AND ALCOHOLIC BEVERAGES TO BE SERVED BY

APPLICANT/LICENSEE.

Name of person, organization, group or association holding the function:

8.	(Caterers Permits for club licensees -- OFF the club premises
ONLY)

I certify that I am an authorized officer of the applicant licensee club; that the function to be held will be exclusively for the use and benefit of the club members only and will be so restricted; that the club has not advertised such affair as open to the public; alcoholic beverages shall be sold only to members attending such function; and that the statements contained in this application are true.

Authorized Officer Signature

Title

Date

9.	(Caterers Permits for club licensees -- ON the club premises ONLY)

The Alcoholic Beverage Control Law provides that a Caterer’s Permit may be issued to a licensed club to cater an affair to be held on the club premises if at least one of the following is applicable (check all that apply):

The particular function or event is to be held by the sodality, auxiliary or other organization affiliated with the licensed club (state which):

A particular charitable or non-profit function or event is to be held by the organization which is a charitable or non- profit organization and such organization has one or more members who are also members of the club (state names):

The function or event is in conjunction with the use of the primary athletic or sports facilities of the licensed club and is to be held by the non-affiliated organization (state name of primary athletic or sports facilities):

The function or event is being held on the club premises because no other suitably licensed premises authorized to sell alcoholic beverages to the public is available within a reasonable distance (set forth the facts to establish foregoing): Use additional sheets if necessary.

I certify that I am an authorized officer of the applicant licensee club; that the club has not solicited the function, nor advertised such function in any manner as open to the public and alcoholic beverages shall be sold only to persons invited to and attending such function, occasion or event; and that the statements contained in this application are true.

Authorized Officer SignatureTitleDate

10.	(Certification to be completed by ALL applicants)
This certification must be signed and dated by:	the individual applicant OR each member of a partnership OR

an officer duly authorized by order of the Board of Directors of the applicant corporation, group or association to make the statements and answers in this application on behalf of said applicant entity, with the same force and effect as if said entity made such statements and answers itself.

I certify that I know the contents of this application and the statements contained therein; that the same are true of my own knowledge; and that I am authorized to execute this application and sign this certification. I further certify that I have read the terms and conditions for the applied for permit and agree to comply with those conditions.

Authorized Signature	Title	Date
Authorized Signature	Title	Date

PROVIDE THE FOLLOWING FOR ALL AUTHORIZED SIGNATURES ABOVE (attach additional sheets if necessary):

		[OFFICE USE ONLY]
Approved	Disapproved	Amount Rec’d					Batch
Audited by				Item		Deposit Date

SLA Form 1011 revised (01/29/04)