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2. Name*
3. Address*
5. Daytime Phone*
6. Email*
8. Person responsible for license*
10. Address/Location of Premises to be Licensed*
    Please include the current use/current business name of location.
12. Date License is needed*
14. Type of License Requested*

    Please check any that apply

    1. Club License
    2. Off-Sale License
    3. On-Sale License
    4. Wine and Beer License
    5. Temporary License (non-profit only)
    6. 3.2% Licenses
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

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