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BEER/ WINE AUTHORITY / TYPE 118 <br />State Form 35494 (R8 111-15) <br />1� Approved by State Board of Accounts, 2016 <br />INSTRUCTIONS, 1, Applicant must complete all requested infonnaf(on. <br />2. Please type or print clearly. <br />3. Submit appllceflon and payment to the focal excise <br />distrlat office. <br />Send, deliver, or mail to: <br />DISTRICT 1 <br />52422 County Road 17 <br />Bristol, IN 46507 <br />Telephone: (574) 264-9480 <br />DISTRICT 2 <br />1353 South Governors Drive <br />Columbia City, IN 46725 <br />Telephone: (260) 244-4286 <br />DISTRICT 3 <br />279 West 300 North <br />Crawfordsville, IN 47933 <br />Telephone: (765) 362-6816 <br />DISTRICT 4 <br />651 S, Commerce Dr. <br />Seymour, IN 47274 <br />Telephone: (812) 523 8314 <br />DISTRICT 6 <br />3650 South US Hwy 41 <br />Vincennes, IN 47501 <br />Telephone: (012) 882-1292 <br />DISTRICT 6 <br />6400 East 30th Street <br />Indianapolis, IN 46219 <br />Telephone: (317)541-4100 <br />STEP 1. GENERAL INFORMATION <br />Name of applicant applying for permit (organization. club, corporation, Individual) <br />Our Lady of Hungary Parish <br />TM Permit number (issued byATC) <br />Address of applicant (numberand street city, state, and ZIP code) <br />735 W Calvert South Bend, IN 46613 <br />E-mall address <br />ddomonkos@sbcsc.kl2.i <br />Name. of person making application <br />Denise M. Dornonkos <br />Fax number <br />( ) <br />Emergency contact telephone number <br />(574) 2551906 <br />Printed name of contact person of event <br />Denise M. Domonkos <br />mergeney con(W telephone number <br />(574) 8493478 <br />STEP 2. EVENT INFORMATION <br />SaVupjay <br />ry)Toy��el�onth, day, year) <br />Ezialurday <br />Tame of event <br />Start time 4 ❑ AM ® PM i End time O <br />❑ AM ®PM <br />Type or description of event <br />Parish Festival <br />71M.816afentRulgibronMIrffendalM04 e) <br />G <br />STEP 3. FLOOR PLAN See Ste 4, Number 2 <br />aJ . <br />a se -cur'- y <br />l_ <br />+ <br />- n� <br />c7- <br />.s <br />vw y <br />��nS <br />vo men 5 <br />�.t},,�om <br />bq+h roam <br />Ga per+ <br />n fro nc Page 1 of 2 Ee h-+rct rz e <br />