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BEER/ WINE AUTHORITY /TYPE 118 <br />State Form 35494 (R10 /3-20) <br />INSTRUCTIONS: <br />1. Applicant must complete all requested information. <br />2. Please type or print clearly. <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). Business checks and money <br />orders made payable to the Indiana Alcohol and Tobacco Commission are accepted. <br />5. Serving past midnight, no later than 3AM, is one (1) dau. <br />6. No rain checks on any of the listed events. <br />Visit hftos://www.in.cov/atcfised2379.htm for additional information about the districts. <br />Deliver or mail completed application and payment to: <br />DISTRICT 1 <br />52422 County Road 17 <br />Bristol, IN 46507 <br />Telephone: (574) 264.9480 <br />DISTRICT 2 <br />1353 South Govemors Drive <br />Columbia City, IN 46725 <br />Telephone: (260) 244-4285 <br />DISTRICT 3 <br />41 West 300 North <br />Cmwrordsville, IN 47933 <br />Telephone: (765) 362.8815 <br />DISTRICT 4 <br />651 S. Commerce Drive <br />Seymour, IN 47274 <br />Telephone: (812) 523.8314 <br />DISTRICT 5 <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 />STEP 1. GENERAL INFORMATION <br />N\8ma^of ��p-p/lic�nt applying forQpensjjL%(orgenizatbn, club, corporation, indwidual) <br />(! <br />TM Pertna number (issued byATC) <br />S '�'U <br />Add <br />�i <br />s of applicant (number and street, dty, state, and 2/P cotle) <br />o� tick - <br />E-mail address <br />�M <br />Name penton making plication <br />(Wit � �� <br />/� <br />Fax number <br />(5-7Y)An(�0 <br />Emergency contact teleone number <br />( �c()2�-I2jg <br />Prin name of con atferson event <br />1a. <br />Emergency contact telephone number <br />(57ti>a�a1aSo) <br />STEP 2. EVENT INFORMATION <br />Beginnin day <br />V.". v <br />Beginning date (month, day, year) dm, day <br />C:� ^ c1. g— <br />Ending date (month, day, year) <br />Time of event <br />Start time IXAM ❑ PMEntl time <br />❑ AM PM <br />Type or description of event <br />Exact address of event (numberand street airy tate, and ZIP code) <br />Viae Iv e) - Pe- rX-Q4 L✓14L(� <br />STEP 3. FLOOR PLAN (See Step 4, Number 2.) <br />� <br />5 1 <br />cp <br />1 <br />Page 1 of 2 <br />