HomeMy WebLinkAbout183843 03/29/2010 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $45.00
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114
INDIANAPOLIS IN 46204 CHECK NUMBER: 183843
CHECK DATE: 3/2912010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4358300 WILLIAMS3 -10 45.00 OTHER FEES LICENSES
APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION
y, 3 Year Employee Permit Type 900 302 W. Washington Street, Rm. E114
2 Year Volunteer Employee Permit Type 801 Indianapolis, Indiana 46204
Employee Permit Section (317) 232 2455
r „s 2 Year Restricted Permit Type 300 Web page: http:Uwww.IN.govlatc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
s STEP 1. GENERAL INFORMATION
Name i appliran1 (hrsf, mi a initial, last) (please print) f Daytime telephone number -1 address
r�f (.G�t� 9 KGB �C' tll�vi
Address (numberan street) Cil�_ State Zip
Social Security Number (Mandatoryper iC 4-1 -8-1 (a) (b)) Sex Height (ft. in. Weight (tbs.) Date of birth month, day, year) Age
D 3-2 f 3 Male Q Female l 3 rf 5� Q 3 3 3
Check one: Permit number (if newal) Check one that applies: Employee Permit 0 19 -20 year old Restricted Permit
r Renewal riginai application Volunteer Permit
me and ad ess of permit premises where this permit is to be used (if known).
pplying for a Volunteer Permit, list the name and address of the not for profit organization.
STEP 2 BACKGROUND QUESTIONS READ CAREFULLY•PRIOR'TOANSWERING
�f Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge in any other state7(if yes,
❑Yes Ito please Ilse the month, day, year, and location of your conviction(s)
Yes 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 awing to the Indiana Department of Revenue ?(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 dented, revoked, or suspended within the last 5 years?lf
Yes ®No yes, explain
[I Yes o 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.
7 1.,Yes ❑No Do you know that it is a Class B Misdemeanor, punishable by up to B 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?
-s ❑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
es []No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEP 3.1920.YEAR OLD RESTAICTEb PERMIT
To recelve a Restricted Employee Permit, you must attach original Certified Server Training Certificate issued to you at your training session. Photocopies
will not be accepted
STEP:4:`:FEE'ANO PAYMENT SCHEDULE
Type 900 3 Year Employee Pemlit(Fee 545.00)
Type 801 -Volunteer Employee Permit (voluntary services only fornonprof)r organizations) (Fee $15.00)
Type 300 2 Year Restricted Pennit(Fee $30.00)
You may work on your receipt for only 30 days
Payment by mail maybe made by money order, business check, or certified check. DO NOT SEND CASH OR PERSONAL CHECKS.
STEP 6.' SIGNATURE AND AFFIRMATION
I certify that this application was completed by myselly affirm under penalties of perjury that I am at least 19 years of age and that all Information provided or
this form is true and t. I unde nd that it isarf 6ny under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be fined.
Signature of Imnl Dale signed (mon day, year)
03 2 /6
Owl Background Check 13 No OWl OWI o No record on file
For-Off lce Use Only Eligible Ineligible
Conviction Date(s) Eligible Date Revealed YES p NO Initial Date
r"
R VOUCHER NO. WARRANT N
u 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 Williams3 -10 43- 583.00 $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
Thursday, March 25, 2010
Director, Brook ire Golf Club
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
ti
Prescribed by Stale Board of Accounts Ci ?y Form No. 201 (Rev 199!
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))
03/24/10 Williams3 -10 Alcohol Permit $45.0
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