2. Contact Person's Name*
3. Email Address*
5. Phone Number*
6. License # (B18XXX)
8. Licensee (This is your LLC, Inc. Name)*
9. DBA (This is the name of your business)*
11. Current License Type*

    1. Specialty Restaurant Beer & Wine License
    2. Specialty Restaurant Beer License
    3. Supper Club
12. Requested License Type*

    1. Retail Beer & Wine
    2. Retail Beer
14. Will there be any changes to your premises?*
    -- Select One --YesNo
15. If changing your premises, attach a sketch
17. Date in which your license will revert back to your present license
    Date in which your license will revert back to your present license
    This temporary license can be effective for up to 90 days.
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field