248386 08/12/15 ��p''• CITY OF CARMEL, INDIANA VENDOR: 355486
ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMMCHECK AMOUNT: S""******45.00*
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 248386
INDIANAPOLIS IN 46204 CHECK DATE: 08/12/15
DEPARTMENT _ ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 LOPEZ 45.00 ORGANIZATION & MEMBER
h APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL&TOBACCO COMMISSION
3 Year Employee Permit-Type 900 302 W.Washington street,Rm.El 14
AI Indianapolis,Indiana 46204
2 Year Volunteer Employee Permit-Type 801 Employee Permit Section(317)232-2455
2 Year Restricted Permit-Type 300 Web page:httpJ/www.[N.gov/ate
State Form 43 Hours:8:00 am to 4:00 pm EST
Approved by State Board of Accounts,2005
STEP..I.GENERAL'INF.. ..
ORMATION
Name of applicant(first middle/mola),last)(please print) Daytime telephone number E- II address
7LISM
Address(number and street) city Stale Zip
l�j ,i di— A 12 1 12MFt_ ZkvDTgNp4 D3 Z
Social Security Number(Mandatory per k 4-1-8-1(a)(b)) Sex Height(lL in.) Weight(lbs.) Date of birth(montt day,year) Age
Male 13 Female Jill" IGS ��
Check one: Permit number(if renewal) Check one that applies: ES Employee Permit 13 19-20 year old Restricted Permit .
0 Renewal ®original application E3 Volunteer Permit
Name and address of permit premises where this permit is to beused(ifknam). 2_ -_�SFfae� c z r eL�,?� 1�12D 132ooKsrh4G �'(W✓J
If applying for a Volunteer Permit,list the name and address of the not for profit organizat on.
BACKGROUND,"QUE$TIONSr READ C,REF.ULLY PRiOR;TD ANSWERING _:' _
Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge in any other state?(Ifyes,
❑Yes IS No please list the month,day,year,and location of yourconviction(s)
❑Yes ®No Aro 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 CRNo 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 PNo yesexplain
❑Yes EffNo 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$1,000 fine,for knowingly serving an intoxicated person?
OYes ❑No Do you know that an excise officer may enter,inspect,and search the pernit premises in which you work without a warrant and you must produce your
pemtit on demand?
IRYes ❑No Do you know that the alcoholic beverage laws are part of the criminal code and are enforceable by every law enforcement officer in the State of Indiana
(Sl Yes ONo Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEP 3 S$-20AAR OLD RESTRICTED PERMI.
To receive a Restricted Employee Permit,you must attaehthe original Certified Server Training Certificate issued to you at your training session.Photocopies
will not be accepted
STEP.4:FEE AND PAYMENT$CHEDULE
Type 900-3Year Employee Pernit(Fee$4500)
Type 801-Volunteer Employee Perrnit(voluntaryservices only for nonproflt 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. 1 affirm under penalties of perjury that I am at least 19 years of age and that all information provided an
this form is true and correcL 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 applicant Dale signed(month,day, ar)
If
D7/312o1S
❑ OWI ❑ OWI
OWI Background Check ❑ No OWI ❑ No record on file
Eligible Ineligible
FOS-Office USB Only Conviction Date(s) Eligible Date initial&Date
Revealed 13 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
$45.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO#/Dept. INVOICE NO. ACCT#!TITLE E
AMOUNT Board Members
1207 I Lopez 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, July 31, 2015
Director, Brookshire Club
Title
,1
Cost distribution ledger classification if I
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))
07/31/15 Lopez Permit $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