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n, —Ie 99 <br />�ell completed <br />�tr13J EI5� <br />application and payment to: <br />DISTRICT <br />'"^ <br />Yf` BEER WINE AUTH0RITY9 01VED <br />State Form 35494 (R10 / 3.20) <br />52422 County Road 17 <br />651 S. Commerce Drive <br />FEBD�e�li�ve,�_, <br />�� ! EB r7 202'� <br />1 F <br />Bristol, IN 46507 <br />Telephone: (574) 264-9480 <br />Seymour, IN 47274 <br />Telephone: (812) 523-8314 <br />INSTRUCTIONS <br />1. Applicant must complete all requested Information. <br />DISTRICT 2 <br />DISTRICT 5 <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 />1353 South Governors Drive <br />Columbia City, IN 46725 <br />Telephone: (260) 244A285 <br />3650 South US Hwy 41 <br />Vincennes, IN 47591 <br />Telephone: (812) 882-1292 <br />orders made payable to the Indiana Alcohol and Tobacco Commission are accepted. <br />5. Serving past midnight, no later than 3 AM, is one (1) day <br />6. No rain checks on any of the listed events. <br />DISTRICT 3 <br />41 West 300 North <br />Crawfordsville, IN 47933 <br />DISTRICT 6 <br />6400 East 30th Street <br />Indianapolis, IN 46219 <br />Telepnone: (765) 362-8816 <br />Telephone: (317) 541A100 <br />Visit hhasYAvwwin.ggy/atcliseo/2379.h1m for additional Information about the districts. <br />STEP 1. GENERAL INFORMATION <br />if Name of applicant applying for permit (wganizaeon, dub, corporation, indivHaal) <br />I TM Pem* number (laeued byATC) <br />St. Adelbert Parish <br />'TX00 Y7"Y 2 <br />Address of applicant (number a9d street, dry, ale, end ZIP code) <br />X l 9 <br />E-mall address <br />2505 W. Grace St. .j I - <br />1 0 ye, 1, <br />rpietrocado@stadelbertschool.org <br />Name of person making ap lcafion <br />Fax number <br />Emergency coned telephone number <br />Fr. Ryan Pletrocado, CSC <br />( 574 ) 251-2786 <br />( 574 ) 288-5708 <br />Printed name of contact person of event <br />Emergemy oontad telephone number <br />Fr. Ryan Plefiwarlo, CSC <br />( 574 ) 334-0049 <br />-: STEP 2. <br />EVENT INFORMATION <br />9eginningday <br />Beginning date (month, day, year) <br />Ending day <br />Ending date (month, day, year) <br />516123 <br />1 5/6/23 <br />5/6/23 <br />5/6123 <br />