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BEER / WINE AUTHORITY I TY3"Iy <br />\ State Form 35494(R1013�20) <br />INSTRUCTIONS: �uN L ZOZ� <br />1. Applicant must complete all requested informal . <br />2. Please type orprint cralmy. <br />3. Submit application and payment to the local excise district office. <br />4. All events are $50 00 per day (905 /AC 1-11.1-1). But ecks and money <br />orders made payable to the Indiana Alcohol and Tobacco Commission am accepted. <br />5. Serving past midnight, no later than 3AM, is one (1) day <br />6. No rain checks on any o1 the listed events. <br />Visit httoslNnnvin.aov/atrsseol2379 htm for additional information about the districts. <br />Deliver or mail completed application and payment to: <br />DISTRICT 1 <br />DISTRICT <br />52422 County Road 17 <br />651 S. Commerce Drive <br />Bristol, IN 46507 <br />Seymour, IN 47274 <br />Telephone: (574) 264-9480 <br />Telephone: (812) 523-8314 <br />DISTRICT 2 <br />1353 South Governors Drive <br />Columbia City, IN 46725 <br />Telephone: (260) 244-4285 <br />DISTRICT 3 <br />41 West 300 North <br />Crawfordsville, IN 47933 <br />Telephone: (765) 362-8815 <br />DISTRICTS <br />3650 South US Hwy 41 <br />Vincennes, IN 47591 <br />Telephone: (812) 882-1292 <br />DISTRICT 6 <br />6400 East 30th Street <br />Indianapolis, IN 46219 <br />Telephone: (317) 541-4100 <br />Page 1 of 2 <br />_Aal <br />STEP 1. GENERAL INFORMATION <br />Name of applican applying <br />for permit ( nizaeon, dub, corporation, indMduali <br />TM Penult number pssuadbyATC) <br />V.rZ <br />C <br />7Nt0o888/5 <br />Mdressdappllwnt(numberendstmet nt,state, <br />7b ll <br />ndZlPcoda) <br />IN kbb3A <br />E-mail address <br />X %3 outVl <br />r ad <br />Name of persoamaking application <br />Fax number <br />Emergency confect telephone num <br />Fmilij Sims> <br />(3(2 ) its. 4-%q <br />Printed n#me of contact person of event <br />Emergency contact telephone number <br />EMIq Sims <br />(50 )IiSATA <br />if <br />STEP 2. EVENT INFORMATION <br />Beginning day <br />Beginning date (monM, day, year) <br />Ending day <br />E:I date (month, day, year) <br />7 <br />"1 <br />Time d wont <br />Stan time 11.30 <br />KAM ❑ PM i <br />Endtime z•3Q <br />❑ AM tj'PM <br />Type or description of event <br />Exact adarbse of nt (nuniberandslinu,4 dry, state, antl Z/Pcode) ��,((��W—y <br />- il <br />STEP 3. FLOOR PLAN (See Step 4, Number2.) <br />See &Ached <br />•' Wrist bands <br />tit, <br />' Uczr 6 <br />P�atter5 i <br />I <br />I <br />I <br />Page 1 of 2 <br />_Aal <br />