HomeMy WebLinkAbout167093 12/17/2008 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM
CHECK AMOUNT: $150.00
CARMEL, INDIANA 46032
CHECK NUMBER: 167093
CHECK DATE: 12/17/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUN DESCRI
1150 4355300 150.00 ORGANIZATION MEMBER
APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO co MMlssloN
2 Year Employee Permit Type 900 302 W. Washington Street, Rm. E114
2 Year Volunteer Employee Permit Type 801 Indianapolis, Indiana 46204
2 Year Restricted Permit -Type 300 Employee Permit Section (317) 232 2455
l° Web page: http: /www.)N.gov /atc
State Form 43 (R16/11- Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2003
STEP 1' `GENERAL INFORMATION
Name of applicant (first, middle initial, last) (please print) Daytime tel ho number E mail r address
CC
Address (number and street) City State
`(q f-1)06� s C,x/ W Zip c�33
Social Security Number (Mandatory perk 4 -1 -8-1 (a) (b)) Sex Height (ft. in.) Weight (lbs.) Date of birth (month, day, year) Age
3 1 y Male Female
Check one: 7
r l l 6 J l�� q 8 2
Permit number (if newal) Check one that applies: JEF Employee Permit 19 -20 year old Restricted Permit
Renewal
riginal application 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.
ac) SH /2 -c' C 6Lf= C6 U(3 I:2 0 r- (�c�oicS� {?c
STEP. 2. BACKGROUND.QUEStIONS.- REAp.CAREFULLY PRIOR,TO AN NG
Have you ever been convicted of operating while intoxicated In Indiana or of a similar charge in any othe
❑Yes QNo month, day, year, and location of your conviction(s) r state? (If yes, please list the
[:]Yes o Are you currently serving a sentence, including any term of probation for operating while intoxicated in Indiana or a similar crime in
another state?
lb []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?
❑Yes No if yes, explain
[]Yes o Have you ever had a drivers license in any other state? if so, you must attach a copy of your driving record from that state.
10 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?
qfg 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?
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
Indiana?
Yes No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEF,3 19 -20 YEAR OLD RES3RICTED +PERMIT_,
To receive a Restricted Employee Permit, you must attach the original Certified Server Training Certificate issued to you at your training session.
Photocopies will not be accepted
STEP 4 FEE AND`PAYMENT,SCHEDULE
rPaymentby Year Employee Permit (Fee $30.00)
lunteer Employee Permit (voluntary services only for nonprofit organizations) (Fee $15.00)
ear Restricted Permit (Fee $30.00)
on your receipt for only 30 days
ail may be made by money order, business check, or c ertified check. DO NOT SEND CASH OR PERSONAL CHECKS.
STEP 5 SIGNATURE AND:AFFIRMATION
1 certify that this application was completed by myself. 1 affirm under penalties of perjury that 1 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.
Sig a re of.. i pplican
Date signed (month, day, earl
V
Owl Background Check No Owl
0 W1 OW
Eligible Ineligible No record on file
For OffCe USe Only r Conviction Date(s) Eligible Date
Revealed YES NO Initial 8 Date
Prescribed by Slate Board of Accounts City Form No. 201 (Rev. 1995)
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
1�c/i�c,yti �lGv hv/ T4 c10 dlnfil t 9 510 aJ Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total SO
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
l
/SD
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or
DEPT INVOICE NO. ACCT #!TITLE AMOUNT I 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
20
Signature
Title ;er
Cost distribution ledger classification if
claim paid motor vehicle highway fund Director of Golf