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Retail Liquor License Name of Event: Applicant Name: Contact Person: Phone # Mailing Address of Applicant: Location of Temporary Dispensing Room: Permit From To #of Calendar days x $50 = Fee This application is for a permit, issued to any retail liquor license holder within the City of Cody. This temporary dispensing room permit authorizes the sale of both alcoholic and malt beverages for sales at meetings, conventions, private parties, dinners or at other similar gatherings in one additional dispensing room in the same building licensed by the original license for a twenty-four hour period. ( W.S. 12-5-201(c)) No person OR organization shall receive more than a total of 6 temporary dispensing room permits in any one year. By filling out this application, I agree to operate in the City of Cody under the requirements of City Ordinances and W.S. 12-4-502 and all other applicable Wyoming laws and rules, and to file required sales tax reporting documents and remit sales taxes. Further, I acknowledge under penalty of perjury that all of the information provided in this application is true and correct. Signature of Applicant Date City of Cody Temporary Dispensing Room Permit A li i