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					                     Vermont Department of Liquor Control
                   Casino or Texas Holdem Event Request Form


The Non Profit organization that is hosting the event must fill out this form and
submit it to the Department of Liquor Control. Please remember when filling out
this form a licensed premises is only allowed three casino events in a calendar year,
a non profit licensed premises may be the site of no more than three casino events in
any calendar quarter and no more than 12 casino events in any calendar year.
These events need to be least 15 days apart. A licensee can only supply the location.
These guidelines can be found in your Title 7 Liquor Law book under section 2143.
If you need assistance please contact your Liquor Investigator or the Vermont
Department of Liquor Control at 802-828-2339.

Licensee Number:_____________________________________________________
Licensee Name: ______________________________________________________
DBA of Licensed premises: ________________________________________________
Telephone number:_______________________________________________________
Email/Fax Number of Licensee_____________________________________________

Non Profit Organization: _________________________________________________
Address:_______________________________________________________________
Contact person__________________________________________________________
Telephone number_______________________________________________________
Email/Fax number_______________________________________________________

Tax exempt #___________________________________________________________
(Of Non Profit)

Date of event: ________________________________

Hours of event: ____________to________________


This form needs to be completed and sent to Vermont Department of Liquor
Control at least thirty days before a scheduled event.

Approval of this form can be denied if this form is not filled out properly and if the
Non Profit Organization does not meet State of Vermont requirements.



DLC Approved.                                            DLC Disapproved.
_______________                                       ___________________

Date:_________________________

				
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