HomeMy WebLinkAbout234460 07/08/14 r.4�q
ti CITY OF CARMEL, INDIANA VENDOR: 355486
ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMMCHECK AMOUNT: $********50.00*
s: a CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 234460
9''��rox�°'_ INDIANAPOLIS IN 46204 CHECK DATE: 07/08/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 50.00 ORGANIZATION & MEMBER
REQUEST FOR EXTENSION
State Form 4125(FMMD-00
-`Renewal Filed`
., Approved by Std Board c f Acrnrurls,2DDO _Fee paid
r _sales tax paid
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Permit namer E
P�m&nrmrber EVtrafiori date
Doing b as 7elephme numbw
Premise address(ramrber and shaet city,shit ZIP )
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Name ofapprirant z
Address(nuibbanwd street;city,state,27P code)
Telephone#1 Telephone Fmc Number
'Check one
•-❑ Sole-proprietor ❑ Corporate officer ❑ Partner ❑IM
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need for an extension(orft renewal)is occasioned by the act or omission of the perffdtfee or his agent then f
9 (eg.Attorney,accaunfarrf
Prepare,etc.). A=.DO extension fee is required.
'i PAY BY CASHIER'S CHECK,.CBMFIED CHECK,BUSINESS CHECK,OR MONEY ORDER TO THE-INDIANA ALCOHOLIC BEVERAGE
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..COMMISSION- (PERSONAL CHECKS CANNOTBEACCFPTED)
Reason:
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❑The need for an extension or the renewal of an axfsiing extension Is oaasioned by the act or Qmiss10n of the Alcoholic Beverage Commission,a
local board,or an unrelated third party who is not an employee of the permittee nor under the control of the permittee.
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I afrmn under perra_AF of pegtrry that an in the request are true and that all safes taxes have been pard,
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�-- 302 West Washington Street
r ' try IGCS Room E114
STATE OF INDIANA Indianapolis, IN 46204
ALCOHOL AND TOBACCO COMMISSION Telephone 317/232-2430
f. Fax 317/234-1520
www.IN.gov/atc
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June 30, 2014
CITY OF CARMEL
12120 BROOKSHIRE PKWY
6..
. Carmel IN 46033
Notice of Missing information from the Alcohol and Tobacco Commission
Permit Number RR2903542
Your application is missing the following item(s) indicated below. Please submit the requested
information along with any forms attached to this notice. The following missing items must be filed
s in sufficient time to process the application otherwise a request for extension will be required to be
filed. Failure to submit the-following can result in delay or denial of your permit.
• Your permit renewals were not submitted 75 days prior to the expiration date. Please
complete the request for extension with the fee of 50.00 per 905 IAC 1-26-2 If the Request
for Extension is not submitted within 30 days after the expiration date you will need to
contact your local Excise office and schedule an inspection before an extension will be
r
granted.
If you have any questions,please contact us at (317) 232-2430.
Thank you in advance for your cooperation.
f>
Please return a copy of this letter with correspondence.
t ;
Indiana Alcohol and Tobacco Commission
302 W. Washington Street Room E 112
Indianapolis, Indiana 46204
Phone: (317) 232-2430 .
-' Fax:,(317) 234-1520
AN EQUAL OPPORTUNITY EMPLOYER
i..` Form Revised 06/23/2010
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Alcohol &Tobacco Commission
IN SUM OF$
302 West Washington Street, Room E 114
Indianapolis, IN 46204
$50.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1207 I permit ext 14 I 43-553.00 I $50.00 1 hereby certify that the attached invoice(s), or
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
Monday, July 07, 2014
Director, Brooks a Golf Club
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
it
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))
07/07/14 permit ext 14 Permit Extension $50.00
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