Application for 6-Month Probationary Cabaret License

Application for 6-Month Probationary Cabaret License
APPLICANT INFORMATION - MUST BE HOLDER OF CLASS B LICENSE
Name of Applicant*

First NameLast Name
Address of Applicant*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Applicant*

Area CodePhone Number
Email of Applicant*
example@example.com
LICENSED ESTABLISHMENT INFORMATION
Name of Licensed Establishment*

First NameLast Name
Address of Establishment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Establishment*

Area CodePhone Number
Email of Establishment*
example@example.com
License Fee - $250.00
List Specific Entertainment*
I, ________________, state that the above information is true and correct to the best of my knowledge, and that if granted a probationary cabaret license, I will abide by all conditions and provisions of Chapter 12.15 of the Code of Ordinance of the Village of Somers under which said licemse is issued.
Signature*

Clear
Date Signed*

MonthDayYear
Return application and fee to:

Village of Somers

Village Clerk

PO Box 197

Somers, WI 53171
OFFICE USE ONLY
Date Received

MonthDayYear
License No.
Period
Should be Empty: