245167 5 /13/2015 �% c�q,�. CITY OF CARMEL, INDIANA VENDOR: 355486
® ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMIVFHECK AMOUNT: $********45.00*
?a CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 245167
9,y,,_ ,. INDIANAPOLIS IN 46204 CHECK DATE: 05/13/15
hrori c�
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 S DAVEGA 45.00 ORGANIZATION & MEMBER
APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL AND TOBACCO COMMISSION
3 Year Employee Permit-Type 900 302 West Washington Street,Room El 14
2 Year Volunteer Employee Permit-Type 801 Indianapolis,Indiana 46204
2 Year Restricted Permit-Type 300 Employee Permit Section:(317)232-2455
°• Web page:http://www.IN.aov/ateatc
State Form 43(R2211-15) Hours:8:00 am to 4:00 pm EST
Approved by State Board of Accounts,2015
'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.
ENERAL INFQRMATION?
Name of applicant(first,middle Initial,last)(please ht) Daytime telephone number E-mail addressjL,
,114
Mailing address(number nd street,city,state,and ZiP code
Social Security Number� �
number(if renewal) Check one that applies.
❑Employee Permit ❑Volunteer Permit ❑19-20 year old Restricted Permit
Name and 7address of permit premises where this permit is to be used lriknown). If applying for a Volunteer Permit,list the name and address of the not for profit organization.
" .� -'STEP 2 BACKGROUND,.(lUE3TIONS„READ CAREFULL,YPRfOR TO;ANSWERING .��„ , ,_ r.: `•�y
Are you aware that you must successfully complete an approved server training course within 120 days of employment? es ❑No
(Not applicable for 19-20 year old Restricted Permit.)
Have you ever been convicted of operating a motor vehicle while Intoxicated in Indiana or of a similar charge in any other state
within the last ten(10)years? (If yes,please list the month,day,year,and location of your conviction(s)): ❑Yes
Are you currently serving a sentence,including any term of probation for operating a motor vehicle while intoxicated in Indiana or a ❑Yes 00
similar crime in another state?
Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue? ❑Yes • Flo
(If yes,you cannot have a permit until all liabilities have been paid.)
Have you had an application for an alcoholic beverage permit or employee's permit denied,fined,revoked,or suspended within the ❑Yes LK0
last five(5)years? If yes,explain:
Have you ever had a driver's license i state identification In any state other than Indiana in the last ten(10)years? ❑Yes RING
If so,you must attach a copy of your driving record from that state.
Do you know that an excise officer may enter,inspect,and search the permit premises in which you work without a warrant and you es ❑No
must produce your permit on demand?
Do you know that the alcoholic beverage laws are part of the criminal code and are enforceable by every law enforcement officer in es ❑No
the State of Indiana?
Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? es ❑No
Do you know that it is a Class B Misdemeanor,punishable by up to six(6)months in jail and a$1,000 fine,for knowingly serving an es _ ❑ -
intoxicated person?
jG r STE20 Y , DESTRIP 3 �9 TD
To ERMIT
receive a Restricted Employee Permit,you must attach the 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—THIS FEE IS NON-REFUNDABLE.)
Type 801-Volunteer Employee Permit(voluntary services only for nonprofit organizations)(Fee$15.00—THiS FEE IS NON-REFUNDABLE.)
Type 300-2 Year Restricted Permit(Fee$30.00—THIS FEE IS NON-REFUNDABLE.)
You may work on your receipt pending issuance of your permit.
Payment by mail may be made by money order,business check,or certified check made payable to the Indiana Alcohol and Tobacco Commission and mailed to
the above address. DO NOT SEND CASH OR PERSONAL CHECKS.
r � ��: r STER`5 SLONATUREANDAFFIRMATION_ ,,,,,;: �s
I certify that this application was completed by myself. I affirm under penalties of perjury that I am at least nineteen(19)years of age and that all
information provided on this form is true and correct. I understand that it is a Level 6 felony under Indiana law to misrepresent or falsify any portion of
this application,and also realize I may be fined.
Signature of pplicant Date signed(month,day,year)
7/11 q c4f.�
'" � x ,'' r. FOR:OFFICEUSE.ONLY
Operating while intobcated(OWI)background check
❑No OWI ❑OWI Eligible ❑OWI Ineligible ❑No record on file
Date(s)of conviction(month,day,year) Date eligible(month,day,year) Revealed Initial Date(month,day,year)
❑Yes ❑No
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Alcohol & Tobacco Commission
IN SUM OF$
302 West Washington Street, Room E 114
Indianapolis, IN 46204
$45.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO#/Dept. INVOICE NO. ACCT#!TITLE AMOUNT Board Members
1207 I S DaVega I 43-553.00 I $45.00 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
Friday, May 08, 2015
Director, Brooks i Golf 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))
05/08/15 S DaVega Permit $45.00
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
120
Clerk-Treasurer