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CITY OF DOUGLAS ONE-DAY ADDITIONAL DISPENSING ROOM PERMIT APPLICATION INFORMATION REGARDING APPLICANT: Name of Liquor Licensee and D/B/A: Name of Primary Contact Person: Address: City: Business Phone Number: Cell Phone Number: INFORMATION REGARDING EVENT: Type of event to be held: Approximate # of people attending: Date permit will be used: Hours of permit: to (am/pm) Location/premise where permit will be used: Define Boundaries of permit area (attach map and diagram showing enclosed consumption and dispensing areas: Security/control/supervision measures to be used in addition to required wristbands (e.g. ID scanner; other means to check IDs; monitoring in place; limited number of entrance/exits; clear cups; etc.): Any person, organization, or licensee who is issued a permit hereunder, shall by operation of the issuance of the permit, indemnify and hold the City, its employees, agents and representatives, including members of the City Council in their representative capacities, harmless from any liability, loss or damage which may be incurred as a result of claims, demands, costs, or judgments arising out of, connected with, or concerning the issuance, use or existence of the permit. SIGNATURE OF APPLICANT DATE OF APPLICATION FOR OFFICE USE ONLY Permit Fee Receipt # Date of Approval Deposit Fee (Required if City property) Date Received License # Issued ---PAGE BREAK--- ****STAFF COMMENTS**** CITY ADMINISTRATOR ADMINISTRATIVE SERVICES DIRECTOR CITY CLERK CHIEF OF POLICE PUBLIC WORKS DIRECTOR COMMUNITY DEVELOPMENT/PLANNING DIRECTOR