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CITY OF JEROME ALCOHOL LICENSE RENEWAL APPLICATION Application for renewal of the license(s) checked below is hereby made: FEE LICENSE REQUESTED (Please mark the appropriate box or boxes) $100.00 Draught, bottled, or canned Beer to be consumed on premises $ 25.00 Bottled or canned Beer to be consumed off premises $200.00 Retail sale of Wine to be consumed on premises (no fee if same premises licensed for sale of liquor by the drink) $100.00 Retail sale of Wine to be consumed off premises $562.50 Retail sale of Liquor by the drink The appropriate fee of $ made payable to the City of Jerome, accompanies this application. Copies of new state and county licenses must be received prior to issuance of the city license. Business name Name of owner or manager CONTACT NAME: Business location Business mailing address CONTACT PHONE: I hereby certify that I have examined the original application for license on file with the City, together with all material required by me to be provided the City for any license renewal, and declare that no changes in any information previously provided has occurred except: None Or As follows: DATED this day of , 20 . Applicant’s Signature STATE OF IDAHO ) ) ss. County of Jerome ) On this day of 20 , before me, the undersigned, a Notary Public in and for said County and State, personally appeared , known to me to be the person whose name is subscribed to the within and foregoing instrument, and who acknowledged to me that he executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and seal, the day and year in this certificate first above written. NOTARY PUBLIC for State of Idaho