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Home My WebLink About233262 06/04/14 CITY OF CARMEL, INDIANA VENDOR: 355486 js ® 31 ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMWHECK AMOUNT: $********75.00* 4 ,q CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 233262 'M,�roN INDIANAPOLIS IN 46204 CHECK DATE: 06/04/14 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4355300 A BRYAN 45.00 ORGANIZATION & MEMBER 1207 4355300 J CAWLEY 30.00 ORGANIZATION & MEMBER APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL&TOBACCO COMMISSION 3 Year Employee Permit-Type 900 302 W.Washington Street,Rm.El 14 G T 2 Year Volunteer Employee Permit-Type 801 Indianapolis,Indiana 46204 Employee Permit Section(317)232 -2455 2 Year Restricted Permit-Type 300 Web page:http://www.IN.gov/atc State Form 43 Hours:8:00 am to 4:00 pm EST Approved by State Board of Accounts,2005 "z s ° x x Yea �4.STP.1:G�fJEf3/�L INORMA,7lON_ 511 w Name of applicant(first,middle initial,last)(please print) Daytime telephone number E-mail address .lark ,4 elo'ka Address(number and street) City Stale Zip Social Security Number(MantfatoryperiC 4-1-8-1(a)(b)) Sex Height(ft.In.) Welght(tbs.) Date of birth(month,day;year) Age 141 Male ❑ Female Check one: Permit number(ffrenewal) Check one that applies: 411�`19-20 year old Restricted Permit ❑Renewal ®Original application 1 ❑ 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. 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 conviction(s) ❑Yes IF No 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 ®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 pa1q7 Have you had an application for an alcoholic beverage permit or employee's permit denied,revoked,or suspended within the last 5 years?lf ❑Yes ®No yesexplain ❑Yes M 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. ilYes ❑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? Nes ❑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 IS Yes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? x ''.. e ` a 5 r`ti�x STEPS i i9r201fEAR OlD,i2ESTRICTEPERMTsx 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 :;. 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. zs S rEF SIGOA TURE RM IIIA 11i�7A 170N r 4 s a "Tom, _ .. a3', 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 ft is a felony under Indiana law to misrepresent or falsify any portion of this application,and also realize I may be fined. Signature of applicant �j Date signed(month,day,year) ❑ OWI ❑ OWI OWI Background Check ❑ No OWI ❑ No record on file For Office*Use OnCy Eligible Ineligible rt.r- Conviction Date(s) Eligible Date - Initial&Date f F O Revealed ❑YES ❑ N i APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL&TOBACCO COMMISSION 3 Year Employee Permit-Type 900 302 W.Washington Street,Rm.E114 Indianapolis,Indiana 46204 2 Year Volunteer Employee Permit-Type 801 Employee Permit Section(317)232-2455 ram. 2 Year Restricted Permit-Type 300 Web page:http:llwww.IN.gov/atc State Form 43 Hours:8:00 am to 4:00 pm EST Approved by State Board of Accounts,2005 GENL".:0 "rtON 3' t sr1 k z 4 t 2 ; . il..tiNF. Na ' of applicant(first,middle initial,last)(please print) Daytime telephone number E-mail address _ Address(number 4ndstreet) City ,� State Zip 1 1153 Sunt-'�sx- C WC �iSl _P_VIE N (DO-32 Social Security Number(Mandatory per 1C 4-1-8-1(a)(b)) Sex Height(ft.in.) Weight(@s.) Date of birth(month,day;year) Age _ ❑ Male l�Female �l - Check one: number(d renewal) Check one that applies: IM-9mployee Permit E3'19-20 year old Restricted Permit E3 Renewal Renewal (3-0riginal application ❑ Volunteer Permit Name and address of permit premises where this permit is to be used(((known). if applying for a Volunteer Permit,list the name and address of the not for profit organization. tJESTIONRJE {�F4 .<.x.^- .. ..X`..�1 �.4x...+. •Yd..e�E ....... __`f.4�.........,.:-.5��... _ ., _.j� . � � 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 13No please list the month,day,year,and location of yourconviction(s) 0Y,as Q 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? ON- Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?Qf yes,you cannot have a permit until ❑Yes o 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 UNo yesexplain ❑Yes f o Have you had a drivers license in any other state in the last 10 years? Iso,you must attach a copy of your driving record from that state. i 4s i]No Do you know that it is a Class B Misdemeanor,punishable by up to 6 months In)ail and a$1,000 fine,for knowingly serving an intoxicated person? Yes ❑No Do you know that an excise officer may enter,inspect,and search the pemut premises in which you work without a warrant and you must produce your lxlpermit on demand? IRYes ❑No Do you know that the alcoholic beverage laws are part of the criminal code and are enforceable by every law enforcement officer,in the State of Indiana Ef Yes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? :-.wvi'��, �a e..s .. t. -r�rT'i to�"Y^ �..�, wr,� s -e �-• s Ys'u x r _ ,:.�4, ;`*� ry�it��"i> u�� '�,5-1•EP�t�$„20`1kE�R QLi�.#tESTA,�i�',I'EE��7T�` '��.`�, "`°x�?at -�x-<x M�v�w�£.,�..^ � 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. y �?[ ( p�(1nE(�fS�GE1 ; �5a a� ?y cz; n, ¢ a;y, ° 1y�'b;6 '..:c+' '" Type 900-3 Year Employee Permit(Fee $45.00) Type 801-Volunteer Employee Permit(voluntary services only for nonprotlt organizations)(Fee$15.00) Type 300-2 Year Restricted Permit(Fee$30.00) You may work on your receipt for only 30 days Payment by mail may be made by money order,business check,or certified check DO NOT SEND CASH OR PERSONAL CHECKS. ,w a i� 161A t?I=11l��'1►Ig � l9 " t `. ., �r_...�.+:e-.n, :_ .,._..,,,-�•�r....-.:.:. ..<s. x_:r.Y,..r.s_�.i.rt? -....,. N?5, �':.;x '�s'ir. s•�.+}xi�.M zip sya'_. I certify that this application was completed by myself. I affirm under penalties of perjury that I am at least 19 years of age and that all information provided o this form is true and torr cL I understand that 8 Ise felo under Indiana law to misrepresent or falsify any portion of this application,and also realize I maybe fined. Signature of applicant Date signed(mo th,day, ear) OWI Backg ound Check ❑ No OWI ❑ OWI 12 OWI ❑ No record on file x Eligible Ineligible F.ot O€[c"e Etse� Eligible Date �� , Conviction Date(s) Initial&DateRevealed 0 YES 0 NO VOUCHER NO. WARRANT NO. ALLOWED 20 Indiana Alcohol & Tobacco Commission IN SUM OF$ 302 West Washington Street, Room E 114 Indianapolis, IN 46204 $75.00 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 1207 A. Bryan 43-553.00 j $45.00 1 hereby certify that the attached invoice(s), or 1207 J Cawley 43-553.00 $30.00 bill(s) is (are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except Thursday, May 29, 2014 Director, Brookshire-wolf Club Title Cost distribution ledger classification if claim paid motor vehicle highway fund Prescribed by State Board of Accounts City Form No.201 (Rev.1995) 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)) 05/27/14 A. Bryan Permit $45.00 05/27/14 J Cawley Permit $30.00 1 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