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HomeMy WebLinkAbout202164 09/27/2011 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1 ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $45.00 CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 INDIANAPOLIS IN 46204 CHECK NUMBER: 202164 CHECK DATE: 9/27/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4358300 45.00 OTHER FEES LICENSES APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION 3 Year Employee Permit Type 900 302 W- Washington Street Rm. El 14 2 Year Volunteer Employee Permit Type 801 Indianapolis, Indiana 46204 Employee Permit Section (317) 232 2455 2 Year Restricted Permit -Type 300 Web page: ht1p: /fwww,1N.gov 1atc rats State Form 43 Hours: 8:00 am to 4:00 pm EST Approved by State Board of Accounts, 2005 `,,STEP t GENERAL ON INFORMATI Name of appli n (first, middie initial, last) (please Oaylime E -mail a Tess pnnt) lele hon numbe d Q_ r a Q Add ss n bran street) Ctt State Z 3 Y' (f Social S a 'Iy Number Cory er,IC -11-1 (a) (b)) Sex Height (4, in.) Weight (tbs.) Dale t h (moot day, year) Male Female Check one: Permit number (drenewal) Check one that app mpioyee Permit 13 19 -20 year old Restricted Permit Renewal Original appll.U.n 1 Volunteer Permit Name and address of permit premises where this permit Is to be used (dknown). if applying for a Volunteer Permit, list the name and address of the not for profit organization. ::,STEP 2': "QUESTIONS: READCAREFUI LY. 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 N11 please list the month, day, year, and location of your conviction(s) Yes No I 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 o Do you have any outstanding and unpaid tax liabilities awing to the Indiana Department of Revenue ?(If yes, you cannot have a permit until all liabilities have been paid) Rave you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the fast 5 years ?!f Yes PO4 yes explain Yes OX. 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. s i3No 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? o ❑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 L/ es ONo Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? 0YEAR OLD PERMlT 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 F1~8`414 D:QAYMENTSCHE6 ULE.; r;t Type 900 3 Year Employee Permit(Fee $45.00) Type 801 -Volunteer Employee Permit(voluntary services only fornonproRt organizations) (Fee $15.00) Type 900 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. STE? 5 .SI6NATURtAN6 AFFIRIt1ATlt)N:,:. 1 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 an this form s t and c ec1. I nderstan that it is a fe, lanv under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be fined. Sig of iiCd Dale.sig ed (moo day, year) Owl Background Check No Owl OWI 13 O I No record on file Ffr Office` Use Only Eligible Ineligible Conviction Dates) Eligible Date Initial Date Revealed ❑YES ONO 1 ;:t. VOUCHER NO. WARRANT NO. ALLOWED 20 Indiana Alcohol Tobacco Commission IN SUM OF 302 West Washington Street, Room E 114 Indianapolis, IN 46204 CJcO ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members I hereby certify that the attached invoice(s), or 1207 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 Friday, September 16, 2011 Director, Brookshir 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 attache invoice(s) or bill(s)) 09/15/11 Alcohol Permit $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 20 Clerk- Treasurer