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2. Name of Establishment*
4. Street Address*
5. City*
7. Licensee Name*
8. Licensee Phone Number*
9. Licensee Email*
11. Brief Description of Entertainment Type Requested*
13. Day(s) Entertainment Will be Presented*
    Day(s) Entertainment Will be Presented Start Date

    —

    Day(s) Entertainment Will be Presented End Date
14. Time(s) Entertainment Will be Presented*
    Time(s) Entertainment Will be Presented Start Time

    —

    Time(s) Entertainment Will be Presented End Time
16. Electronic Signature Agreement. *

    By selecting the "I Accept" button, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature.

    1. I Accept
17. Print Name*
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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