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BEER I WME At k RITY I TYPE 118 <br />State Form &rA94 (R8 111 111- 5) 5) <br />.w <br />Approved ty state Board of is, 201 5 <br />jNSTRUr,Tjopjs- 1. Applicant must complete all requested info"36017* <br />Z Please type arprint cleady- <br />3, subroft application and Payment to Me kwaf excise <br />distdct office. <br />Send, deliver, or mail to: <br />DISTRICT 1 <br />52422 county Road 17 <br />Bristol, IN 46507 <br />Telephone: (574) 264940 <br />DISTRICT 2 <br />1353 sot& Govemom Drive <br />Columbia City, IN 46725 <br />TetephGw. (260) 244-4296 <br />DISTRICT 3 <br />279 West 300 North <br />Crawfordsville, IN 47933 <br />Telephone. (765) 362-81115 <br />DISTRICT 4 <br />651 S. Commerce Dr. <br />Seymour, IN 47274 <br />Telephone: (612) 523-8314 <br />DISTRICT 5 <br />3650 south Us Hwy 41 <br />Vincennes, IN 47591 <br />Telephone: t812) 892-1292 <br />DISTRICT 6 <br />6400 East 301h Street <br />Ind-tanapoUs. IN 46219 <br />Tolephane: (317) 641-4100 <br />STEP 1. GENERAL tNFORMAMON -ym Permit number (issued by ATC) <br />Name 10[f applicantappyng for permit (organizatiN4 dub, corporation, individuaO PermItnumbr(' wed " ATC' <br />address ad EE <br />N%+', Gaa" `Ac— E-mail address <br />A of pUcant (nmtherandstreet cffY.,F�ft and ZfPcOde) <br />do w <br />ro 0\-& 00 LtD Af --I mtdlu co -be' <br />Fax number Emergency contact telephone number <br />Name of person MAking application <br />.p <br />gjej�.tact contact telephone .6crei, S-ftWV4 <br />Printed narW of contact person 01 event <br />STEP 2. EVENT INFORMATION <br />Ending date ("th, <br />day, year) <br />Beginning day <br />wknllil/ <br />Beoning date (MOnth, dag YeO <br />Ending day 14'�djt, <br />110 <br />Time of event <br />9 <br />El I'm <br />End time <br />E] AM PNI <br />start time <br />Type or desclipti0fl 01"even'., <br />WYV <br />C&A <br />Exact address of event (Vber and t <br />c* estate, and ZZJJPPI 0069 <br />jV q L <br />I <br />k Vd STEP & FLOOR PLAN (See S'hP4- N"Ther 2' <br />-------------- <br />.. . . ....... <br />Page i of 2 <br />