184326 04/14/2010 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $45.00
r' CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114
INDIANAPOLIS IN 46204 CHECK NUMBER: 184326
CHECK DATE: 4114/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4358300 BARINGER 45.00 OTHER FEES LICENSES
VAL APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION
3 Year Employee Permit Type 900 302 W. Washington Street Rm. E114
2 Year Volunteer Employee Permit -Type 801 Indianapolis, Indiana 48204
e Employee Permit Section (317) 232 2455
faro 2 Year Restricted Permit Type 300 web page: http: /Avww.IN.gov /atc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by Stale Board of Accounts, 2005
STEP 1. GENERAL: INFORMATION'
Na of a plicant middle initial, last) (please print) DayBme telephone number E -mall address
fU�Ar/! I`. i�r, pf 1 7e -e /J I 13 36 r.a l.c.o,h
Address (numberandsfreel) City State p
33 C C V c,,+ St�� lUobleslr �l� IN) Cl�o�a
Social Security Number (Mandatory per IC 4 -1 -8-1 (a) (b)) Sex Heig (8. in.) r ighs (lbs.) Dale of irth nfh, day, year) Age
Mate 13 Female b S b8r1� 9,? 7
Check one: Permit number (ffrenewall Check one that applies: a Employee Permit 19 -20 year old Restricted Permit
Renewal I Original applicaEion I Volunteer PemUl
Name and address of permit premises where this permit is to be used (if known). rtio 2 C FF C to 6 12 J V PIL y r^ e r
If applying for a Volunteer Permit, list the name and address of the not for profit organization.
STEP 2.. BACKGROUND QUESTIONS READ. CAREFULLY PRIORTO ANSWERING
r Have you ever been convicted of operating a motor vehicle while Intoxicated in Indiana or of a similar charge in any other state ?(If yes,
Yes 0 please list the month, day, year, and location or 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?
Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue ?(Ifyes, you cannot have a permit until
0 Yes 1�(N.
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?!f
Yes ho 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.
6 Yes 0 N 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?
E
AY es ❑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?
L LYes ❑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
itYes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEP 3.19- 20.YEAR OLD RESTRICTED PERMIT
To receive 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=AND PAYMENT SCHEDULE
Type 900 .3 Year Employee Permit(Fee $45.00)
Type 801 -volunteer Employee Permit(voluntary services only for nonprot7t 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.
STEPS. SIGNATURE AND AFFIRMATION.'..
I certify that this application was completed by myself. I affirm under penalties of perjury that I am at least 19 years of age and that all information provided on
this form is true and correct. I understand that it is a fetonv under Indiana law to misrepresent or falsify any portion of this application, and also realize t maybe fined.
Signature of applicant Date slgn (moni day, year)
OWI Background Check No OWI OWI O El No record on file
For Of 6e.Use Only Eligible ineligibbll e
Conviction Date (s) Eligible Date Initial Date
Revealed YES 13 NO
VOUCHER NO. WARRANT NO.
-1 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 Baringer 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
Tuesday, March 30, 2010
Z'e� d 1,4Z
Director, Brookshir 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. 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))
03/26/10 Baringer 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