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2. Name of Entity*
4. Function*
6. Date (s) and Time of Dance*
   Date (s) and Time of Dance

   Date (s) and Time of Dance
7. Number of People Attending*
9. Are There Alcoholic Beverages to Be Served or Consumed on the Premise?*

   1. Yes
   2. No
11. If yes, a banquet permit must be issued by the Washington State Liquor Control Board. It must be presented at the time of application and a copy provided to the City.
13. Permit Number*
    Permit can be purchased at your local liquor store. Call 787-2729
15. Is this dance admitting minors (17 and under)?*

    1. Yes
    2. No
17. Is there a cover charge?*

    1. Yes
    2. No
18. if yes, please list chaperones*
20. Security will be provided by*
    Please provide name and address
22. The undersigned will save and hold harmless the City of Quincy from all loss, liability or expense resulting from any injury to any person, or any loss of damage to any property, caused by or resulting from any act or omission of the undersigned or any member of their organization.
24. Signature*
25. Date*
    Date
27. Name*
28. Organization*
30. Address*
31. Phone*
33. Owner of Premises*
34. Phone*
36. Address*
39. Date*
    Date
41. $15 Permit Fee Paid*

    1. Yes
42. Date Paid*
    Date Paid
43. Receipt Number*
Leave This Blank:


44. Print Only

* indicates a required field