HomeMy WebLinkAbout196397 04/13/2011 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK AMOUNT: $45.00
INDIANAPOLIS IN 46204
CHECK NUMBER: 196397
CHECK DATE: 4113/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4358300 PERMIT 45.00 OTHER FEES LICENSES
WA
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 46204
Employee Permit Section (317) 232 -2455
2 Year Restricted Permit Type 300 Web page: http:/Avww.IN.gov1atc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
7
Yr'
TEP1..GENERA
GENERA
Name of applicant (First. middle initW, last) (please print) Daytime telephone number
E-mail address
1 V (A C' LM I D V e
7
Address (number and streell) Wcky city F�_ State A/ Zip
Social Security NuMber (Mandatory per/iC a 1.8 -1 (a) (b)) Sex Height (tt. in-) Weight (lbs of til (month day, year) Age
(-(
1%,Male C3 Female
Check one: Permit number (ifrenewal) Check one that apples: 0 Employee Permit 19 -20 year old Restricted Permit
Renewal �6riginal application 1 1 Volunteer Permit
Name and address of permit premises where this permit is to be used (ilknown).
If applying for a Volunteer Permit, list the name and address of the not for profit organization.
OR',_
Ult��flbWS READ C,kR&(j1LC
P,
TOANSWF
rt
Q s No lWave you ever been convicted of operating a motor vehicle while Intoxicated in Indiana or of a similar charge In any otherstate?(Ifyes.
Ye please list the month, day, year, and location of your convieflon(s)
Yes N Are you currently serving a sentence, Including any term of probation for operating a motor vehicle while Intoxicated in Indiana of 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
OYes 1K NO all liabilities have been palo
E]Ye s No 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. explain
Yes Pile 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.
X lyes P No Do you know that it is a Class 8 Misdemeanor, punishable by up to 6 months in jail and a $1,000 fine, for knowingly serving an intoxicated person?
19 Y 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
Y pennit on demand?
es ❑No I 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 Indian
7 21[Yes ❑No 10o you understand that this employee permit is yours and that your employer Is only allowed to copy the permit?
PERMIT
To receive a Restricted Employee Permit, you must attachthe origina Certified Server Training Certificate Issued to you at your training session. Photocopies
will not be accepted.
h
F E E AND'PAYMENT SC HED U LE
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 mall may he made by money order, business check, or certified check. DO NOT SEND CASH OR PERSONAL CHECKS.
T
'S
ttpt�&fdNATURE AND AFFIRMATIO
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 corr eeCl understand that it is a ftLqU under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be fined.
Signature of appljcentf
Date sign r( onlh, ay, year)
i f
Owl Background Check No Owl 11 owl 'Ow No record on file
Eligible Ineligible
oeOW16 ug6 O frly
(s)
k 7
ConvictonDate Eligible Date Initial Date
Revealed YES NO
VO UCHER N O. WARRANT NO,
ALLOWED 20
Indiana Alcohol Tobacco Commission
IN SUM OF
302 West Washington Street, Room E 114
Indianapolis, IN 46204
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO# Dept. INVOICE NO. ACCT #ITITLE AMOUNT Board Members
I hereby certify that the attached invoice(s), or
1207 Permit Veach 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
Tuesday, March 29, 2011
4
Director, Broo"JAhire 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))
03/28/11 Permit Veach Chris Veach $45.0
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
2fl
Clerk- Treasurer