F-3 Permit Application {DLC 4189}

F-3 PERMIT APPLICATION THE FEE FOR AN F-3 PERMIT IS $300.00 An F-3 permit may be issued to a non-profit organization of 250 or more members whose primary purpose is to support, promote, and educate members of the beer, wine, or mixed beverage industry. An F-3 permit allows the organization to bring beer, wine, or mixed beverages in their original packages or containers into a convention facility or hotel, not for sale, for consumption in the facility or hotel for a period not to exceed five days. Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 Telephone No. (614) 387-7407 http://www.com.ohio.gov/liqr SECTION (A) Name of Organization: PROPOSED F-3 PERMIT PREMISES INFORMATION Name of Hotel or Convention Facility: Township (if outside city limits): Zip Code: County: Street Address: City: Mail and/or Fax Permit and Correspondence To: Name: State: Zip Code: Street Address: Phone #: Name: Phone #: City: Fax #: Title: Individual responsible for the compliance with Ohio's liquor laws in conjunction with the sale and consumption of alcoholic beverages: Date and Time Function Will Begin: Date and Time Function Will End: Date Function Begins: Date Function Ends: Time Function Begins: Time Function Ends: am am pm pm SECTION (B) APPLICANT/ORGANIZATION INFORMATION 2. What is the Organization's Non-Profit Tax Exempt Certificate #: NOTE: FAILURE TO PROVIDE THE FOLLOWING INFORMATION WILL RESULT IN THE IMMEDIATE REJECTION OF THIS APPLICATION 1. List Total Membership of Organization: 3. Please provide the Top Four Officers of the Organization: Name: Residence Address: Phone: Name: Residence Address: Phone: Title: Title: Name: Residence Address: Phone: Name: Residence Address: Phone: FOR OFFICE USE ONLY Title: Title: Taxing District Permit Number Receipt # DLC4189 Reviewer Action: Remarks: Rev. 1-07 American LegalNet, Inc. www.FormsWorkFlow.com SECTION (C) ORGANIZATION INFORMATION 1. Please describe the organization's purpose: 2. Please describe the organization's purpose for the event: SECTION (D) THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT(S): State of Ohio, ___________________________________County, ss I/We ___________________________________________________, being first duly sworn, according to law, depose (Print Name and Title) and say that I/We are at least twenty-one (21) years of age and the statements and answers made in the foregoing application are true __________________________________________ (Signature of Officer of Organization) ______________________________ (Title of Officer of Organization) (This portion to be completed by Notary Public) Sworn to before me and subscribed in my presence this ________ day of ________________________________, 20_______. _________________________________________________________ Notary Public Expiration Date TO ENSURE THAT THIS APPLICATION IS PROCESSED AS QUICKLY AS POSSIBLE, PLEASE SUBMIT THE FOLLOWING ALONG WITH THIS COMPLETED, SIGNED, AND NOTARIZED APPLICATION $300.00 Permit Fee Completed & signed Consent Form Completed and signed "Diagram of Permit Premises for F-3 Liquor Permit" form and any attachments. Explanation of any officer's conviction for any felony or misdemeanor, if applicable. Current Certificate of Good Standing from the Ohio Secretary of State's Office indicating the organization's Not-for-Profit status. EOE/ADA SERVICE PROVIDER Page 2 FOR TTY USERS DIAL ORS 1-800-750-0750 American LegalNet, Inc. www.FormsWorkFlow.com DIAGRAM OF PROPOSED PERMIT PREMISES FOR "F-3" LIQUOR PERMIT THIS DOCUMENT MUST BE COMPLETED IN ORDER TO OBTAIN YOUR TEMPORARY PERMIT Every applicant for an F-3 liquor permit must submit, with the application, a diagram of the premises where alcoholic beverages will be consumed. If the diagram is not included, the application will be returned to the applicant. The diagram can be submitted in the space provided below or on a separate sheet and signed by the person who prepared the diagram or the applicant. The diagram must identify the room(s) in which alcoholic beverages will be consumed. DIAGRAM MUST APPEAR IN THE SPACE BELOW, OR INDICATE ATTACHED SHEET _________________________________________________________ Signature of person who prepared diagram _________________________________________________________ Print Name Title Phone # Page 3 American LegalNet, Inc. www.FormsWorkFlow.com CONSENT TO/NOTIFICATION OF F-3 LIQUOR PERMIT CONSENT OF HOTEL OR CONVENTION FACILITY The ___________________________________________________ hereby grants consent for the use of a portion of (name of hotel or convention facility) the property located at ________________________________________ to ___________________________________________ (address of hotel or convention facility) (name of organization) to conduct a function: beginning _____________________________________ (Date Function Begins) at (Time Function Begins) am am pm pm and ending ____________________________________ (Date Function Ends) at __________________ (Time Function Ends) Check all that are applicable and complete This hotel or convention facility is a liquor permit premises, permit number ______________________. The hotel or convention facility will suspend those permit privileges in the portion of the hotel or convention facility where the F-3 liquor permit event will take place, as that portion is indicated on the "Diagram of Proposed Permit Premises for F-3 Liquor Permit." This hotel or convention facility is not a liquor permit premises. This hotel has at least fifty rooms for registered transient guests and is licensed pursuant to R.C. 3731.03. _________________________________________________ (Signature of general manager or equivalent officer) _______________________________________________ (Title) _________________________________________________ (Print Name) _______________________________________________ (Day time telephone number) NOTIFICATION OF CHIEF PEACE OFFICER This portion must be completed by the Chief Peace Officer in the municipality or township where this function will be held indicating that they have been notified of the date, time, place, and duration of the event. (If the township does not have a Chief Peace Officer, the County Sheriff's Department must be notified accordingly.) I, _________________________________________ the Chief Peace Officer of ______________________________________ (Name) (City, Township, or County) do hereby acknowledge notification that ___