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HomeMy WebLinkAbout184795 04/27/2010 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1 f l ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM 4� CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK AMOUNT: $135.00 'y INDIANAPOLIS IN 46204 CHECK NUMBER: 184795 CHECK DATE: 4/27/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4358300 45.00 GREASER 1207 4358300 90.00 VASIL /CHAPMAN APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL &TOBACCO COMMISSION 3 Year Employee Permit -Type 900 302 W. Washington Street Rm. El 14 C 2 Year Volunteer Employee Permit Type 801 Indianapolis, Indiana 46204 Employee Permit Section (317) 232 2455 2 Year Restricted Permit Type 300 Wear page: http:/Awm IN.govlatc Slate Form 43 Hours: 8:00 am to 4:00 pm EST Approved by State Board of Accounts, 2005 STEP 1. GENERAL INFORMATION Name of ira (first, middle initial, last) (p /a. lease print) �j �5 Daytime telephone number E-mail address �..t O .e cL. 37 l ?IW6 c 0 rl..l 1 C��- •1.1 L� •C 1^�� Address (number and street) City State Zip 1 3d-9 se P- ter au-" e_ 1 _-T-_ 1 Social Securily Nomhar rr+= a (a) (b)) Sex Height, (ft in.) Weight (0sj Date of birth ((month, day, year) Age E3 Male Female r 4r 1 ,�Ac L O r 7 Chec one: v Permit number (ffrenewal) Check one that applies: Employee Permit 13 19 -20 year old Restricted Permit Renewal .t9 Original application I 1 Volunteer Permit Name and address of permit premises where this permit is to be used (if known). if applying for a Volunteer Permit, list the name and address of the not for profit organization. STEP 2. BACKGROUND CtUEST1ON5 READ CAREFULLY'PRIOR TO 'ANSWERING 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 29 No please list the month, day, year, and location of yourconvlctfon(s) Are you currently serving a sentence, including any term of probation for operating a motor vehicle while Intoxicated in Indiana or a similar Yes 12 No crime in another state? Yes No Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue ?(lf yes, you cannot have a permit untll pit llablilUes 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?lf ❑Yes t3No 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. `1 eyes ❑No Do you know that R is a Class B Misdemeanor, punishable by up to 6 months in Jail and a $1,000 fine, for knowingly serving an intoxicated person? Yes 13 No Do you know that an excise officer may enter, inspect, and search the permit p rdmises In which you work without a warrant and you must produce your permit on demand? Yes []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 Yes ❑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 nonprofit 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 o this form is true and correct i understand that it is a fgoy under Indiana iaw to misrepresent or falsify any portion of this application, and also realize I may be fined. Signature of applicant Date signed (month, day, year) 7 iJ V owl OWI Background Check 13 No OWI lig b e Ineligible No record on file For Office Use Only Conviction Date(s) Eligible Date Initial Date Revealed 0 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 Greaser 4/26/10 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 Monday, April 26, 2010 Director, Brook hire 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)) 04/24/10 Greaser 4/26/10 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 r APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL_ TOBACCO COMMISSION 8 ton Street, Rm. E114 302 W. Washi 3 Year Employee Permit -Type 900 g 3 Indianapolis, Indiana 46204 2 Year Volunteer Employee Permit -Type 801 Employee Permit Section (317) 232 -2455 2 Year Restricted Permit Type 300 Web page: http: /www.IN.gov /atc State Form 43 Hours: 6:00 am to 4:00 pm EST Approved by State Board of Accounts, 2005 STEP 1. GENERAL INFORMATION Name of applicant (first, middle initial, last) (please print) Daytime telephone number E-mail address s5 (number �l numberandstreet) City State Zip 1 Social Security Number (Mandatory per 1C 4 -1 -8 -1 (a) (b)) Sex y Height (it. in.) Weight (tbs.) Date of birth (month, day, year) Age Male (q Female 3 4 I l ao 1 0 1 -O 3 V16-7 I S a Check one: Pemrit number (il renewal) Check one that applies: P Employee Permit 13 19 -20 year old Restricted Permil Renewal 10 Original application Volunteer Permit Name and address of permit premises where this permit Is to be used (d known). if applying for a Volunteer Permit, list the name and address of the not for profit organization. STEP 2. BACKGROUND QUESTIONS READ:CAREFULLY PRIOR TO ANSWERING.: 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 No please list the month, day, year, and locatlon of yourconvlctlon(s) Are you currently serving a sentence, Including any term of probation for opbrating a motor vehicle while intoxicated in Indiana or a similar ❑Yes ,No crime in another state? 1 11 Yes No 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 paid) 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 No yes explain 0 Yes ONo 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. �l 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? J 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 I�il es No permit on demand? I Ives ❑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 Stale of Indiana `r Yes ❑NO Do you understand that this employee permit is yours and that your employer Is only allowed to copy the permit? STEP 3. 49 20.YEAR OLD RESTRICTED kRMIT To receive a Restricted Employee Permit, you must attach ortytrial 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 nonprofit 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. STEIR 6.: SIGNATURE AND AFFIRMATION I certify that this application was completed by myself. I affirm under penalties of perjury that 1 am at least 19 years of age and that all information provided o this form is true and correct I understand that d 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 Date signed (month, day, year) Owl Background Check No Owl ©fig b e I isle No record on file For Office Use Only Conviction Date(s) Eligible Date Initial Date Revealed YES NO APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION 3 Year Employee Permit Type 900 302 W. Washington Street, Rm. E114 Indianapolis, Indiana 2 Year Volunteer Employee Permit Type 801 17 23 Employes Permit Section (317) 232 2455 2 Year Restricted Permit Type 300 Web page: http:/hwAv.IN.gov/atc State Form 43 Hours: 8:00 am to 4:00 pm EST Approved by State Board of Accounts, 2005 STEP 1. GENERAL INFORMATION Name of ap icon SS ffrsl, middle initial, last) (please print) Daytime telephone number E -mail address i f— L. 3I4 1c) (A«ItL11e__A rk0., Address (numbe an C State Zip «D ZI M (I( Ix f n S i t e_ �Lt 0 2� 4 L 0 3 3 Social Sen,rity Number W— t— r1o rr, 4,t— l (a) (b)) Sex Height (R. In.) (tbs.) Date of irih (mo lh, dey, 'year) Age Male Ij C Female l� 2 1 6 l 9 b 1 L 41 Check one: Permit number (irrenewal) Check one that appiles: Employee Permit 19 20 year old Restricted Permit Renewal P roriginal application Volunteer Permit Name and address of perm t premises where thks permit is to be used (d known). (CS /J r oa, (so j-Y (21 f 19 7 If applying for a Volunteer Permit, list the name and address of the not for profit organization. Q lG5✓ 1 r STEP 2. BACKGROUND QUESTIONS READ CAREFULLY PRIOR TO ANSWERIN Have you ever been convicted of operating a motor vehicle while Intoxicated in Indiana or of a similar charge in any other state ?(lf yes, Yes l( No please list the month, day, year, and location of your convictlon(s) Yes 16 No Are you currently serving a sentence, including any term of probation for opbrating a motor vehicle while intoxicated in Indiana or a similar crime In another state? Yes [M No Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(lf 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, revoked, or suspended within the last 5 years ?lf ❑Yes IONo yes explain Yes R(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. I@ Yes ❑No Do you know that 0 is a Class 5 Misdemeanor, punishable by up too months in jail and a $1,000 fine, for knowingly serving an intoxicated person? (9Yes []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? Oyes []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 indlana eyes []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 800 3 Year Employee Penmit (Fee $45.00) Type 801 Volunteer Employee Permit (voluntary services only for nonprofit 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 6. 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 felony under Indiana law to misrepresent or falsify any portion of this application, and also realize i may be fined. Signalure of ap icanl Date si Id (mon1h day, year) Owl Background Check No OWI E lig b e Ineligible No record on file For Office US13 Only Conviction Date(s) Eligible Dale Initial Date Revealed 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 $90.00 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members 1207 VasiA -10 43- 583.00 $45.00 I hereby certify that the attached invoice(s), or 1207 Chapman -10 43- 583.00 $45.00 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 Wednesday, April 14, 2010 Director, Brook ire 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 19T 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)) 04/12110 Vasil4 -10 Permit $45.0 04/13/10 Chapman -10 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