HomeMy WebLinkAbout197239 05/11/2011 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM
0 302 W WASHINGTON ST ROOM E114 CHECK AMOUNT: $45.00
CARMEL, INDIANA 46032
INDIANAPOLIS IN 46204 CHECK NUMBER: 197239
CHECK DATE: 5/11/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 GENTRY4 -11 45.00 ORGANIZATION MEMBER
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
,e- 2 Year Restricted Permit Type 300 Web page: http:Ihvww.IN.goviatc
State Form 43 Hours: 5:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
Na of applicant (first, middle rmbal, ast) (please print) Daytime telephone number E-fn dressy
b` d oa y A, c'� e-�rCq 3 r� q 7 3 �n J
Address (number and street) City State Zip
31 5. L wc,:s 1. bt a17D
Social Security Number (
m Male E] Female I f:) � 3071
Check one- Permit number (ffrenewal) Check one that applies: Employee Permit 13 19 -20 year old Restricted Pemut
Renewal tifQriginal application Volunteer Permit
Name and address of permit premises where this permit is to be used (ifknown). n
If applying for a Volunteer Permit, list the name and address of the not for profit organization. �rr�kSh Flo CllrJ
a
D�QUESTI
N
CKGFtQUdSNS„: jREAD, '"GAREFULIY�PRIORTOANSVIfiERING
Have you ever been convicted of operating a motor vehicle while in I ated In Ind ana or of a similar charge in any other state ?(!f yes,
i3Yes No please list the month, day, year, and location of your conviction(s) SJt l
Yes a 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?
El Yes 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?ff
❑�Yees o y 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.
es No I 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?
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?
V
Oes ❑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.
Fd Yes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
u
r41 i f 3 a f .i STEP >.3 19;20 YEAR:OLD RESTTRICTED PERMIT ��s m_ 0
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
r .,#a,�� aiSTEP4 ;FEE.AND;PAYMENTSCHE[1LiLEa 2rai z
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.
rSTEPS.SIGNATUREAND,AFFIRMAION
I certify that this application was completed y myself. I 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 correct. I understand tha it is a feionv under fndiana law to misrepresent or falsify any portion of this application, and also realize I may be fined.
Signature of ap Date signed (month, day, year)
Ll J-1
yak 11 owl 11 owl
Background Check No Owl Eli gible Ineligible E3 No record on file
�For¢��ce�CJseaOniy'�
I k
iY11 Conviction Date(s) Eligible Date Initial Date
Revealed YES 13 NO
VOUCHER NO. 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
ZZ
�O# l De.: INVOICE NO ACCT# /TITLE AMOUNT
3card Pv1 Der
Cc(J['y that the attached invoices), Cr
1207 Gentry4 -11 43- 553.00 $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 27, 2011
Director, Broo 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))
04/26/11 Gentry4 -11 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