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 Name Last Name
Address of Applicant *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Applicant *

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

First Name Last Name
Address of Establishment *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Establishment *

Area Code Phone 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 *

Month Day Year
Return application and fee to:

Village of Somers

Village Clerk

PO Box 197

Somers, WI 53171
OFFICE USE ONLY
Date Received

Month Day Year
License No.
Period
Should be Empty: