HomeMy WebLinkAbout202599 10/11/2011 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: 202599
u o i
CHECK DATE: 10/11/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMB AMOUNT DESCRIPTION
1207 4358300 BABCOCK 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
Indianapolis, Indiana 46204
2 Year Volunteer Employee Permit Type 801 Employee Permit Section (317) 232-2455
2 Year Restricted Permit -Type 300 Web page: http:1/wwyv.IN.govlatc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
li�" bit" I W 06kkiCT] 6 h
Name, ofapplicant (Arit. middle inilkil s12 (please p� �t et;J Daytime telephone number E-mall address
e 41eldl-balz- e 60
Address (number and street) city State
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aA
Soci
r) Ag ;4'_
Check one: Permit number (if renewal) Check one that applies: -Employee Permit 1 9 -20 4ea, old Restricted Pen
Renewal )�2rlglnal application I I E3 Volunteer Permit
me
Name and address of permit premises where this permit is to be used (if known).
2
r1f apptyrng for a Volunteer Permit, list the name and address of the not for profit organization.
„:STEP 2i BACKGROUNQ Y.
S CA 'U PRIDR;TO ANSWERING
Have you ever been convicted of operating a motor vehicle while intoxicated In Indiana orofa similar charge in any other state?(If yes,
Yes 'qNo I please list the month, day, year, an location of your conviction(s)
Are you currently serving a sentence, Including any term of probation for operating a motor vehicle while Intoxicated In Indiana of a similar
Yes No crime In another state?
yes No Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(Ifyes, you cannot have a permit until
t 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 ANO yes, 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.
Yes ❑No Do you know that R Is a Class 8 Misdemeanor, punishable by up to 6 months In jail and a $1,000 fine, for knowingly serving an Intoxicated person?
I 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?
]Yes [3No 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 Indianal
Y es es []NG Do you understand that this employee permit is yours and that your employer Is only allowed to copy the permit?
P E RMIT.
RE EP ;19 2 YEAR RE
AT 3.
To receive a Restricted Employee Permit, you must adachthe origina Certified Server Training Certificate Issued to you at your training session. Photoeooies
will not be accepted.
--s Z STEP: FEE =AND 'PAYMENT tcktDotE
Type 900 3 Year Employee Permit(Fee $45.00)
Type 801 Volunteer Employee Permit (voluntary services only for nonprorit 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.
STEP;S. SIGNATURE AND AFFIiiii ON
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 an
this form is true and correct I u erstand that it is akLqU under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be fined.
Signature of applica Date :igMmpnM day, year)
Owl Background Check 13 No Owl 13 owl owl 0 No record on file
F or Oflicedlls 6 Eligible Ineligible
Conviction Date(s) Eligible Date Initial Date
Revealed YES ONO
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
PO# Dept. INVOICE NO- ACCT #ITITLE AMOUNT Board Members
I hereby certify that the attached invoice(s), or
1207 Babcock -10 -11 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, October 07, 2011
fj 4,
Director, Brookshi e 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))
11
10/06/11 Babcock -10 -11 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