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Licant Information 1. Organization Name: 2. Contact's Last, First Name 3. Email Address 4. Address 5. City/State/Zip 6. Cell Phone # 7. Fax # 8. Alternate Contact & Phone On Site Responsible Party (Must be at least 21 years of age) 9. Will applicant/contact be in attendance at this event? 10. Is applicant/contact the responsible party for the event? Yes No Yes No If applicant is NOT the responsible party on site for this event, please complete items #11 14. If so, go to #15. 11. Resp.

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