APPLICATION FOR LARGE ATTENDANCE FACILITY ALCOHOLIC BEVERAGE PERMIT
City of Fayetteville, 113 West Mountain, Fayetteville, AR 72701
Regulated by Title XI, Chapter 111 of the City of Fayetteville Code of Ordinances
Please print or type the following:
Business Applicant
Name:
(Must be person listed on State Permit)
Address:
City, State, Zip:
Phone:
Mailing Address:
Date of Birth:
*ALL INFORMATION MUST BE FILLED OUT
Driver’s License #:
BEFORE APPLICATION WILL BE PROCESSED.
Permit fee - $500.00
If this is a new establishment, I do hereby swear and affirm that the location of this business for which this permit is
sought is not within 200 yards of any church or school building, if said business is a retail establishment for the sale of
alcoholic beverages for consumption off the premises; or is not within 300 feet of any church or school building for
any other business for which a City of Fayetteville alcoholic beverage permit is required.
Affidavit – The below signed applicant, being 21 years of age or older, after first being duly sworn, states that all
above information is true and accurate to the best of his or her knowledge and belief.
Applicant’s signature
(Must be person listed on State Permit)
Subscribed and sworn before me this day of , 20
Notary Public
(Seal)
My commission expires
A COPY OF YOUR CURRENT STATE PERMIT MUST ACCOMPANY THIS APPLICATION
