The URL can be used to link to this page

Home My WebLink About161407 07/11/2008 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1 0 ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $45.00 CARMEL, INDIANA 46032 CHECK NUMBER: 161407 CHECK DATE: 7/11/2008 DEPARTMENT ACCO PO NUM INVOICE NUMBER AMOUNT DES CRIPTION 1205 4355300 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 "hero" 2 Year Restricted Permit Type 300 YP Web page: http: /www.IN.gov /atc State Form 43 Hours: 8:00 am to 4:00 pm EST Approved by Slate Board of Accounts, 2005 INF x O GENERAL,ORMATION,� Name of applicant (first, middle initial, last) (please print) Daytime telephone number E -mail address n. �EPt40 C �I��E�IL)t.SCl 317 571 -24 03 ®Qnn�vt�+ �tN,�:iov Address (number and street) City State Zip Social Security Number (Mandatory per IC 4 -1 -8 -1 (a) (b)) Sex Height (R. in.) l Weight (lbs.) Date of birth (month, day, year) Age Male Female Z t �(7 UL�f 3 !�1'� 3 (O� Check one: Permit number (it renewal) Check one that applies: [Er Employee Permit 19 -20 year old Restricted Permit Renewal Original 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. °STEP 2'1BACKGRQU,NDzOUESTIONS _E2EAD CAREFUL LY PRIOR TOANSI!VERING d�`_ P 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, El Yes 2 please list the month, day, year, and location of your conviction(s) Yes 8 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? Yes nNo Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue /f 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 o yes, explain ❑,,/Yes [�T10 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. LIYes ❑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? ❑'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? O Yes E] 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 121 Yes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? r r r r STEP,319= 20!YEAR OLD REST RICTED;PERMIT, °.��,¢r4 receive a Restricted Employee Permit, you must attach original Certified Server Training Certificate issued to you at your training session. Photocopies accepted gE�ANDPAYMENT�,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. UR��MSTEPSSiGNATUI2EANQi4l FIRMi4lION� a�� axt; ,50 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 d 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. Signature of ap Dale signed (month, day, year) OWI OWI �t Owl Background Check No Owl No record on file Ineligible Eligible e Ineli Or OfflCtr USt?Only r Conviction Date(s) Eligible Date Initial Date z Revealed YES NO Prescribed b;: State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) 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. A= Payee z� Indiana Alcohol &Tobacco Commission Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 07/09/08 Appli ation fo, Employee Pe-Mlit for Steve $45. 00 Fnaelking Total 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. 07/07/08 ALLOWED 20 a Indana Alcohol Tobacco Commis IN SUM OF 302 W. Washington Street, Rm. E114 Indianapolis, IN 46204 $45.00 ON ACCOUNT OF APPROPRIATION FOR GENERALFUND 1205 Administration 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 00 materials or services itemized thereon for which charge is made were ordered and received except 20 Si nature W 4� Title Cost distribution ledger classification if claim paid motor vehicle highway fund