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Home My WebLink About231725 04/23/14 ,CAA . "' CITY OF CARMEL, INDIANA VENDOR: 355486 ® it ONE CIVIC SQUARE INDIANA ALCOHOL & TOBACCO ComWHECK AMOUNT: $....***120.00* } :° CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 231725 q��TON�` INDIANAPOLIS IN 46204 CHECK DATE: 04/23/14 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4355300 CMINNAAR 30.00 ORGANIZATION & MEMBER 1207 4355300 SJONES 45.00 ORGANIZATION & MEMBER 1207 4355300 SMINNAAR 45.00 ORGANIZATION & MEMBER -STA APPLICATION APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL&TOBACCO COMMISSION ton Street,Rm.El 14 302 W.Washington 3 Year Employee Permit-Type 900 g Indianapolis,Indiana 46204 2 Year Volunteer Employee Permit-Type 801 Employee Permit Section(317)232-2455 2 Year Restricted Permit-Type 300 Web page:http://www.IN.gov/atc rere State Form 43 Hours:8:00 am to 4:00 pm EST Approved by State Board of Accounts,2005 Nam applicant(first iddle initial,last)(please print) Daytime telephone nuber E-mail address i'l `., . 7 ��1�X12-`��`� S�JQ►�'��j 2 �jjr Address(number and Peet) City State Zip J Z. \�- .fin 6j,� - V) � V'1 G Z S Social Security Number(Mandatoryper IC 41-8-1(a)(b)) Sex Heigh (ft.in.) Weight(lbs.) Date of birth(month, ay,year) Age Male ❑ Female Check one: Permit number(if renewal) Check one that applies: Employee Permit ❑ 1 -20 yea old Restricted Permit ❑Renewal Original application ❑ Volunteer Permit Name and address of permit premises where this permit is to be used(if known). If applying for a Volunteer Permit,list the name and address of the not for profit organization. „:STEP 2 BACKGROUNDtQUESTiONS„READ.CAREFULLY PRIOR Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge in any other state?(If yes, ❑Yeso please list the month,day,year,and location of your conviction(s) Are you currently serving a sentence,including any term of probation for operating a motor vehicle while intoxicated in Indiana or a similar ❑Yes ° crime in another state? Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(If yes,you cannot have a permit until El Yes `5 No all liabilities have been paid) �� Have you had an application for an alcoholic beverage permit or employee's permit denied,revoked,or suspended within the last 5 years?if ❑Yes No yesexplain ❑Yes o Have you had a drivers license in any other state in the last 10 years? If so,you must attach a copy of your driving record from that state. s ❑No Do you know that it is a Class B Misdemeanor,punishable by up to 6 months in jail and a$1,000 fine,for knowingly serving an intoxicated person? Yes ❑No Do you know that an excise officer may enter,inspect,and search the permit premises in which you work without a warrant and you must produce your permit on demand? yes ❑No Do you know that the alcoholic beverage laws are part of the criminal code and are enforceable by every law enforcement officer in the State of Indiana. _es ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? • _�; - �,.,STEP3.19 20 YEAR•OL4'RES,TRIGTED PERMIT ,�-•,,,,,Y �- To receive a Restricted Employee Permit,you must attachthe original Certified Server Training Certificate issued to you at your training session.Photocopies will not be accented. '.`.FEE`AND;;PAYMENSCHEDULE, Type 900-3 Year Employee Permit(Fee $45.00) Type 801-Volunteer Employee Permit(voluntary services only for nonprofit organizations)(Fee$15.00) Type 300-2 Year Restricted Permit(Fee$30.00) You may work on your receipt for only 30 days Payment by mail may be made by money order,business check,or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. STEPS',SIGNATUREAND AF_F.IRMATION I certify that this application was completed by myself. I affirm under penalties of perjury that I am at least 19 years of age and that all information provided o this form is It d corre71 I understand that it is a felony under Indiana law to misrepresent or falsify any portion of this application,and also realize I may be fined. . Signature of appli t Date signd o h,day,year) OWI Background Check 1:1 No OWI ❑ OWI ❑ OW ❑ No record on file Eligible Ineligibl For;Office;Use On Conviction Date(s) Eligible Date Initial&Date Ys Revealed ❑YES 0 NO �• `"p APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL&TOBACCO COMMISSION 3 Year Employee Permit-Type 900 302 W.Washington Street,Rm.El 14 ' 2 Year Volunteer Employee Permit-Type 801 Indianapolis,Indiana 20a g Employee Permit Section(31177)232-2455 fere 2 Year Restricted Permit-Type 300 Web page:http:/Avww.IN.gov/atc State Form 43 Hours:8:00 am to 4:00 pm EST Approved by State Board of Accounts,2005 STEP 1.GENERAL INFORMATiON Name of applicant(first,middle initial,last)(please print) Daytime telephone number E-mail address Sher-).son M. ti1I Nrl AAf— 3i �)S�`1 `I�iG(o ScimIhi,a.�,��c�:1h1rnk of Address(number and street) City State Zip 3 _!R.a rl vv�a-I) C C v K T C A P-rA L I N 1 40 d 33 Social Security Number(Mandatory per IC 4-1-8-1(a)(b)) Sex Height(R.in.) Weight(lbs.) Date of birth(month,day,year) Age ❑ Male 12 Female Check one: Permit number(if renewal) Check one that applies: Employee Permit ❑ 19-20 year old Restricted Permit . ❑Renewal '15k0dgina1 application I I ❑ Volunteer Permit Name and address of permit premises where this permit is to be used(if known). if applying for a Volunteer Permit,list the name and address of the not for profit organization. STEP'.2:BACKGRQUND,QUESTIONS='REA[QCAREFULLY.PRIORTOANSWERING ` Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge in any other state?(If yes, ❑Yes No please list the month,day,year,and location of your convicUon(s) [3 Yes CNo Are you currently serving a sentence,including any term of probation for operating a motor vehicle while intoxicated in Indiana or a similar crime in another state? ❑Yes IP No Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(!f yes,you cannot have a permit until all liabilities have been pato Have you had an application for an alcoholic beverage permit or employee's permit denied,revoked,or suspended within the last 5 years?ff ❑Yes ONO yes,explain ❑Yes [ANo Have you had a drivers license in any other state in the last 10 years? If so,you must attach a copy of your driving record from that state. ZYes ONO Do you know that it is a Class B Misdemeanor,punishable by up to 6 months in jail and a$1,000 fine,far knowingly serving an intoxicated person? Ves ❑No Do you know that an excise officer may enter,inspect,and search the permit premises In which you work without a warrant and you must produce your permit on demand? t]dYes []No Do you know that the alcoholic beverage laws are part of the criminal code and are enforceable by every law enforcement officer in the State of Indiana 1Yes ❑No IDo you understand that this employee permit is yours and that your employer is oNy allowed to copy the permit? - "'•"�' ` STEP.3.19=20.YERRtOLD�RESTRICTED,PERMIT::' To receive a Restricted Employee Permit,you must attachthe orinfnal Certified Server Training Certificate issued to you at your training session.Photocopies will not be accepted. " �, -; STEP 4::FEE'AND PAYMENT SCHEDULE':' Type 900-3 Year Employee Pernit(Fee $45.00) Type 801-Volunteer Employee Permit(voluntary services only for nonprofit organizations)(Fee$15.00) Type 300-2 Year Restricted Permit(Fee$30.00) You may work on your receipt for only 30 days - Payment by mail may be made by money order,business check,or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. STEPT-,,SIGNATURE AND AEFIRMATION I certify that this application was completed by myself. I affirm under penalties of perjury that I am at least 19 years of age and that all information provided o this form is true and correct. I understand that it is afelonv under Indiana law to misrepresent or falsify any portion of this application,and also realize I may be fined. Signature of appy r Date signed(month,day,year) ackground Check ❑ No OWI ❑ OWI ❑ OWI ❑ No record on file Eligible Ineligible For Offtce,Ust3.Only.: Conviction Date(s) Eligible Date Initial&Date Revealed ❑YES ❑NO I t f°"Pm APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL&TOBACCO COMMISSION 3 Year Employee Permit-Type 900 302 W.Washington Street,Rm.Eli at` Indianapolis,Indiana 46204 2 Year Volunteer Employee Permit-Type 801 Employee Permit Section(317)232-2455 2 Year Restricted Permit-Type 300 Web page:http:/iwww.IN.goviatc State Form 43 Hours:8:00 am to 4:00 pm EST Approved by State Board of Accounts,2005 ":. STEP.1:GENERALINFORMATION Name of applicant(first,middle initial,fast)(please print) Daytime telephone number E-mail address �h 1�2 1�er� /✓✓4 rnRa- 3 i'- 7- Address(number and street) City State Zi 3 :if orlLUPOC) Cou(-4-- Cott'f�� l N L4603 Social Security Number(Mandatory perk 41-8-1(a)(b)) Sex Heigi t(ft_fn.) Weight(lbs.) Date of b/i�th(month,day,year) Age ❑ Male Female Check one: Permit number(if renewal) Check one that applies: ❑ Employee Permit 19-20 year old Restricted Permit . 13 Renewal Original application ❑ Volunteer Permit Name and address of permit premises where this permit is to be used(if known). If applying for a Volunteer Permit,list the name and address of the not for profit organization. ;STEP_2:BACKGRQUND=QUESTIONSr;READ'CAREFUL_L'-Y.PRIOR=TO'ANSIMERING: . ; Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge in any other state?(If yes, ❑Yes WNo please list the month,day,year,and location of your convictfon(s) Are you currently serving a sentence,including any term of probation for operating a motor vehicle while intoxicated in Indiana or a similar ❑Yes ISINO crime in another state? ❑Yes No Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(If yes,you cannot have a permit until all liabilities have been pall Have you had an application for an alcoholic beverage permit or employee's permit denied,revoked,or suspended within the last 5 years?if ❑Yes No yes,explain ❑Yes No Have you had a drivers license in any other state in the last 10 years? if so,you must attach a copy of your driving record from that state. eZwo Do you know that it is a Class B Misdemeanor,punishable by up to 6 months in jail and a$1,000 fine,for knowingly serving an intoxicated person? WYes ❑No Do you know that an excise officer may enter,inspect,and search the permit premises In which you work without a warrant and you must produce your permit on demand? Yes ❑No Do you know that the alcoholic beverage laws are part of the criminal code and are enforceable by every law enforcement officer in the State of Indiana Yes r_3No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? STEP,3. PERMI r` To receive a Restricted Employee Permit,you must attachthe original Certified Server Training Certificate Issued to you at your training session.Photocopies will not be accepted. STER.4."FEE AND PAYMENT SCHEDULE ` Type 900-3 Year Employee Pernit(Fee $45.00) Type 801-Volunteer Employee Permit(voluntary services only for nonprofit organizations)(Fee$15.00) Type 300.2 Year Restricted Permit(Fee$30.00) You may work on your receipt for only 30 days Payment by mail may be made by money order,business check,or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. STEP..S:SIGNATURE AND AFFIRMATION I certify that this application was completed by myself. I affirm under penalties of perjury that i am at least 19 years of age and that all information provided o this form is true and correct. I understand that it is a felony under Indiana law to misrepresent or falsify any portion of this application,and also realize I may be fined. Signature of applican Date signed(month,day,year) 0 owl r 4i �c iaot OWI Background Check ❑ No OWI ligib el Oeligible ❑ No record on file For Offce.USe Only:'Conviction Dates) Eligible Date Initial&Date Revealed 0 YES ❑NO Ci Form No.201 Rev.1995 Prescribed by State Board of Accounts City ( ) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 03/30/14 S Minnaar Permit $45.00 04/09/14 S Jones Permit $45.00 04/09/14 I C Minnaar I Permit I $30.00 I hereby certify that the attached invoice(s), or bill(s), is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 20 Clerk-Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 Indiana Alcohol & Tobacco Commission IN SUM OF $ 302 West Washington Street, Room E 114 Indianapolis, IN 46204 $120.00 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 1207 S Minnaar 43-553.00 $45.00 1 hereby certify that the attached invoice(s), or 1207 S Jones 43-553.00 $45.00 bill(s) is (are) true and correct and that the 1207 I C Minnaar I 43-553.00 I $30.00 materials or services itemized thereon for which charge is made were ordered and received except Friday, April 11, 2014 Director, Brookshire olf Club Title Cost distribution ledger classification if claim paid motor vehicle highway fund