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Application For Limited Special Occasion Permit - North Carolina

Application For Limited Special Occasion Permit Form. This is a North Carolina form and can be used in Alcoholic Beverage Control Commission Statewide .
 Fillable pdf Last Modified 12/17/2010
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NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Location: 400 E. Tryon Road Raleigh NC 27610 (919)779-0700 APPROVED REJECTED BY: DATE: AMOUNT FEE PAID: DATE: RECEIVED BY: TEMP. #: MAIL TO ADDRESS ON BACK OF FORM (Do Not Write Above This Line) APPLICATION FOR LIMITED SPECIAL OCCASION PERMIT A. B. C. D. Complete the application by typewriter or print in ink. All applicants' signatures must be notarized. Limited Special Occasion fee is $50.00. The fee must be submitted by certified check, cashier's check, or money order, and made payable to the North Carolina Alcoholic Beverage Control Commission. E. Submit a copy of the lease/rental agreement or complete "Lease Information" on the back of this form. F. The original copy of the applicant's Criminal Record Check. I hereby make application for a Limited Special Occasion permit which authorizes me to transport, possess, and serve fortified wine and spirituous liquor to my guests at a reception, party, or other special occasion. The event will be held on the premises of a business with the permission of the owner of the property. Check One: Individual Limited Partnership Partnership Limited Liability Company Date: (in which event takes place) Corporation County: Individual's Full Name: First (no abbreviations) Middle Last Date of Birth: If representing corporation, give corporation name: Trade Name of Location where event held: Location of event: Street/Route City State Zip Code Special Event: Date Time Event Begins Date Time Event Ends IF PERMIT IS TO BE MAILED BY COMMISSION, GIVE NAME AND MAILING ADDRESS: NAME: MAILING ADDRESS: Application for Limited Special Occasion Permit Rev.11/10 American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT INFORMATION Resident Address: Street/Route City State Zip Code Home Telephone #: Daytime Telephone #: ( ( ) ) Fax #: Business Telephone #: ( ) ( ) email address I CERTIFY UNDER OATH OR AFFIRMATION THAT: - I am not the owner or possessor of the premises applied for. - I am not less than 21 years of age. - I have not been convicted of a misdemeanor controlled substance offense or alcoholic beverage offense within the past two years. - I have not been convicted of a felony within the past three years, and if convicted of a felony before then, I have had my citizenship restored. - I have not had an alcoholic beverage permit revoked within the past three years. - I have the written permission of the owner of the property to serve alcoholic beverages. - The information on this application is correct to the best of my knowledge. - The information on this application is correct to the best of my knowledge. - I understand that failure to abide by the ABC laws may result in the immediate revocation of my privilege to sell/serve alcohol. Signature of Applicant Sworn to and subscribed before me this the Day Month Year My commission expires: Notary or other person qualified by law to administer oaths Lease Information As owner/lessee of the premises, I have no objection to: _____________________________ LSO Applicant receiving a Limited Special Occasion Permit for use on said premises on the date of Day Month Year Owner/Lessee ( ) Business Telephone # Telephone # Date MAIL THIS APPLICATION TO: If sending by U.S. Postal Service (regular mail): If sending by U.S. Postal Service EXPRESS MAIL or by FEDEX/UPS: NC ABC COMMISSION 4307 MAIL SERVICE CENTER RALEIGH NC 27699-4307 NC ABC COMMISSION 400 E. TRYON ROAD RALEIGH NC 27610 Application for Limited Special Occasion Permit Rev.11/10 American LegalNet, Inc. www.FormsWorkFlow.com
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