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Home My WebLink About234036 06/25/14 CITY OF CARMEL, INDIANA VENDOR: 355486 .l ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMM%HECK AMOUNT: $********65.00* ,_�; CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 234036 9�'��tOfl LA` INDIANAPOLIS IN 46204 CHECK DATE: 06/25/14 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4355300 10.00 B BALLARD 1207 4355300 45.00 C VEACH 1207 4355300 10.00 R HIGGINS INDIANA ALCOHOL&TOBACCO COMMISSION APPLICATION FOR REISSUE 302 West Washington Street,Room E114 State Form 47667(R2/1-14) - Indianapolis,Indiana 46204 Y� Approved by State Board of Accounts,2014 Telephone:(317)232-2430 Feu Web page:www.IN.aov/atc This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1;disclosure is mandatory and this record cannot be processed without it. The fee for reissue is$10.00. Payment may be made by mail using a money order,business check,or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. FOR OFFICE Cash receipt number Date of reissue(month,day,year) Date of expiration(month,day,year) APPLICANT INFORMATION Name of permittee - AJ Social Security Number' Permit number Daytime telephone number Address of permittee(number and street,city,state,and ZIP code) a8 Even t.r` �0 ��. e e q(o 0 7q REISSUE INFORMATION Type of certificate to be reissued(check one) ❑Alcoholic beverage ❑Tobacco ❑ Businessmployee Reason for reissue(check one) ❑Original document never received(lost in mail) ❑Original document lost ❑Original document stolen ❑Original document destroyed ❑Articles of Amendment(Name change;copy of Articles of amendment must be attached.) ❑Articles of Merger(No change in ownership;copy of Articles of Merger must be attached.) SIGNATURE AND AFFIRMATION I understand that the original certificate is null and void upon reissuance and if I recover the original certificate, I must forward it to the Indiana Alcohol and Tobacco Commission. I affirm under the penalties of perjury that the foregoing representations are true and correct. Signature of applicAnt Date(month,day,year) Type or printed.name of applicant ATS $ INDIANA ALCOHOL&TOBACCO COMMISSION APPLICATION FOR REISSUE sot West Washington Street,Room El 14 s State Form 47667(R2/1-14) Indianapolis,Indiana 46204 �y Approved by State Board of Accounts,2014 Telephone:(317)232-2430 Web page:www.IN.gov/atc This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1;disclosure is mandatory and this record cannot be processed without it. The fee for reissue is$90.00. Payment may be made by mail using a money order,business check,or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. FOR OFFICE USE ONLY Cash receipt number Date of reissue(month,day,year) Date of expiration(month,day,year) APPLICANT INFORMATION Name f permittee Social Security Number• Permit number Daytime telephone number . . X32 o ��' Address of permittee(number and street,city,state and ZIP code .� (lrG�cwl �� q6 6e C REISSUE INFORMATION Type of certificate to be reissued(check one) ❑Alcoholic beverage ❑Tobacco ❑ Business mployee Reason r reissue(check one) Original document never received(lost in mail) ❑Original document lost ❑Original document stolen ❑Original document destroyed ❑Articles of Amendment(Name change,copy of Articles of amendment must be attached.) ❑Articles of Merger(No change in ownership;copy of Articles of Merger must be attached.) SIGNATURE AND AFFIRMATION I understand that the original certificate is null and void upon reissuance and if I recover the original certificate, I must forward it to the Indiana Alcohol and Tobacco Commission. I affirm under the penalties-of perjury that the foregoing representations are true and,correct. Signatu cant Date(month,day,year) TypedA printed name of applicant APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL&TOBACCO COMMISSION y 3 Year Employee Permit-Type 900 302 W.Washington Street,Rm.Ell 2 Year Volunteer Employee Permit-Type 801 lee Permit e ti n( 46204 _ Employee Permit Section(317)232=2455 !' MIS ¢ 2 Year Restricted Permit-Type 300 Web page:http:uwww.IN.gov/atc State Form 43 Hours:8:00 am to 4:00 pm EST Approved by State Board of Accounts,2005 c.'Ya 1: ��.. "�.�. . P,1�,t'y E £�i�11A'[IO �j �, : Name of Pplicanl(first;middle initial,last)(plea print) Daytime telephone number E-rwil address �. e z 3 f, X16 -_?I l C`�t/ �► Cv►z•�-or i. Address(numberands et) �� City i C State Zip , %ZI i) -Svc J - f a Social Security Number(Mandatory perk 4-1-8-1(a)(b)) Sex IHZht(ft in.) JW ht(lbs.) Date offbirt (monM,day-,year) Age — Male [3Female 1 Check one: Permit number(d r newail Check one that applies: Employee Permit ❑ 19-20 year old Restricted Permit ❑Renewal Original application I I ❑ Volunteer Permit Name and address of permit premises where this permit is to be used(Irknown). it o D 0 C aJy I If applying for a Volunteer Permit,list the name.and address of the not for profit organization. (2_12- iC�� 1 G_ OCIS1� LT ,tJ1�l( RdCc >. " �1_. _ i _ ... P41o�r�G, l- l�f f Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge In any other state?pfyes, ❑Yes No please list the month,day,year,and location of your convictlon(s) t Are you currently serving a sentence,including any term of probation for operating a motor vehicle while Intoxicated in Indiana or a similar ❑Yes No crime in another state? JDo you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(If yes,you cannot have a permit until [3 Yes ° 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 El 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. Yes ❑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 pem18 on demand? es 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 ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? K.. . . 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 x�ew^'%' � � s�:.+,a�� :�` '��S �� T�SS�;E � .;, =� ti�i}�r��k - ti �c's`�s4rv✓�a� r� - 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. y.. 1 certify that this application waloppleted 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. rate A that it is a felon under Indiana law to misrepresent or falsify any portion of this application,and also realize I may be fined. Signature of applicant Date signed(mont,day,year) � 6 (�\dui.. F V - ❑ OWI ❑ owl OWI Background Check ❑ No OWI ❑ No record on file F.or f3fIcCCse OACEligible Ineligible ¢ � y Conviction Date(s) Eligible Date Initial&Date ?, Revealed ❑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 $65.00 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO#/Dept. INVOICE NO. ACCT#IrITLE AMOUNT Board Members 1207 R Higgins 43-553.00 $10.00 1 hereby certify that the attached invoice(s), or 1207 B Ballard 43-553.00 $10.00 bill(s) is (are)true and correct and that the 1207 I C Veach I 43-553.00 I $45.00 materials or services itemized thereon for which charge is made were ordered and received except k Thursday, June 19, 2014 Director, Brookshire If 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 I Invoice Invoice Description Amount Date Number (or note attached invoice(s)or bill(s)) 06/19/14 R Higgins Replace Permit $10.00 06/19/14 B Ballard Replace Permit $10.00 06/19/14 I C Veach I Permit Renewal I $45.00 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