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A. n •`a <br />y ) LOCAL AUTHORIZATION FOR TEMPORARY BEER & WINE PERMIT APPLICATION <br />•�% <br />INSTRUCTIONS: 1. Applicant must complete all requested inlormation. <br />2. Please type orprint Geady. <br />3. Obtain the requlmd communttyclea once signatures and upload with the online temporary event applicahon. <br />NOTE: THIS FORM IS ONLY TO BE USED WITH ONLINE APPLICATION. Visit https://mylicense.in.gov/eGavIMLI.himi to submit the online application. <br />r�L <br />STEP 1. GENERAL INFORMATION <br />Name of applicant applying for permit (organization, dub, corporation, individual - Such 88XYZ 123 /no) <br />-"'TLAK II` F.-i2 Q.>•2f W jr%) & I M 6 L. L C <br />Address of applicant (number and street, oily, state, and ZlP-cudei <br />l e rui/6 .iT Nrrd GiYws4,e lip% 7, fZ <br />E-mail address <br />x x, as l'o <br />Printed name of person making �a �licafion <br />/ �rfic� <br />Fax number <br />(Si/)2335/5 <br />Emergency contact tgfephons number <br />liu>) i/C:r �Nsxc/ <br />Printed name of contact person of ev nl <br />-5 rY„ ��ry' :: �;�,: �„ice <br />Emergencycenlacltelephonenumber <br />(5-13) y7& -J7K i <br />STEP 2 EVENT INFORMATION <br />Beginning day (Monday, Tuesday, of) <br />5A SIlL, 1-L" 10Z <br />Segmninff dale (month, day, year) Ending day (Monday, Tuesday, etc) <br />r�7/JZ Z3 _S:+i!/JL/) r/ <br />EM dale (mont , day, year) <br />b} IZI7>- <br />Imeof went <br />Startgme /n ®AM OPM End time / <br />f n rG./ <br />?� DAM ®PM <br />Type or description of avant <br />C:aAssa <br />Exact address of event (number and street, city, state, and ZIP code) T <br />ZD\ CH S`KIi IiT S>.,i/r� /J�.d:,uJ / .F� �t✓r�(%� <br />STEP A FLOORPLAN <br />Jt <br />STEP C APPLICANT VERIFICATION <br />The below signed applicant affirms under the pareldu o/perjury Met the iniormadon contained in this /orm is true and accurate. <br />signature ;/Picanl <br />Dalesigned (moth, da <br />STEP S. COMMUNITY CLEARANCE <br />I. Sign/ety/feP( enMof nly,a/r�Chiefo •i ipr1mvn rsha1l cljudadklion where the event will be held <br />T l l /�/� <br />Date signptlZ(monlh.pay, ye)> y� <br />.� G <br />2. Signature of the mayor (d the events held in Fort Wayne) <br />Date signed (month, day, year) <br />