178211 10/14/2009 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
j ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK AMOUNT: $90.00
INDIANAPOLIS IN 46204 CHECK NUMBER: 178211
CHECK DATE: 10/14/2009
DEPARTMENT ACCOU PO N INVOICE NUMBER AMOUNT D ESCRIPTION
1207 4358300 90.00 OTHER FEES LICENSES
"'��w APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION
3 Year Employee Permit Type 900 302 W. Washington Street, Rm. El 14
g Indianapolis, Indiana 46204
2 Year Volunteer Employee Permit Type 801 Employee Permit Section (317) 232 2455
rer. 2 Year Restricted Permit Type 300 Web page: http: /lwww.IN.gov /atc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
STEP 1: GENERAL INFORMATION
Name of appticani (first, middle initial, last) lease print) Daytime telephone number E -mail address
Address (number and street) City State 12 4 W S� (1L C6 92MOL 33
Social Securit Number Mandate IC 4 -1 -8-1 (a) (b)) Sex Height (!t. In.) Weight (Ibs.) Date of birth (month, day, year) Age
Male 13 Female (
Chet one: Permit number (Ifr newal) Check one that applies: Employee Permit E3 19 -20 year old Restricted Permit
Renewal dginal application Volunteer Permit
Name and address of permit premises where this permit is to be used (fiknown), 12— i Z O 13 2WLSs k y C 7C
it r_e e p W r .T 44, 3
if applying for a Volunteer Permit, list the name and address of the not for profit organization.
'•STEP.2` BACKGROUND. QUESTIONS READ CAREFULLY PRIOR' ,0ANSWERING
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,
E3 Yes 1 310 please list the month, day, year, and location of your convicilon(s)
Are you currently serving a sentence, Including any term of probation for operating a motor vehicle while intoxicated In Indiana or a similar
❑Yes o me in another state?
Yes o 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 fabllifies have been paid)
Have you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the fast 5 years ?If
Yes o yes explain
Yes 911. Have you had a drivers license In any other state in the last 10 years? It so, you must attach a copy of your driving record from that state.
❑Yes o 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?
KK. ❑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
0 No
permit on demand?
es 11 00No 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 E3No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEP 3.,19- 20.YEA14 Of:D RESTRICTED PERMIT
To receive a Restricted Employee Permit, you must attach orlainal Certified Server Training Certificate issued to you at your training session. Photocopies
will not be accepted
STER4: =FEE AND PAYMENT SCHEDULE
Type 900 3 Year Employee Permit (Fee $45.00)
Type 801 Volunteer Employee Permit (voluntary services only for nonprollt organizations) (Fee 575.00)
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 6i :SIGNATURE AND AFFIRMATION
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 on
this form is true and correct. I understand that it is a felon tinder Indiana law to misrepresent or falsify any portion of this application, and also realize I may be fined.
Signature of apptican Dale signed (month, day, year)
1p
-7-
09
OWI Background Check No OWI OWI OWI No record on file
For Office Use Oniy Eligible Ineligible
Conviction Date(s) Eligible Date YES NO Initial Date
Revealed
S APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION
i 3 Year Employee Permit Type 900 302 W. Washington Street Rm. El 14
a
Indianapolis, Indiana 462
2 Year Volunteer Employee Permit Type 801
Employee Permit Section (317) 23 232 2455
2 Year Restricted Permit Type 300 Web page: http:lAvww.]N.gov /atr
Slate Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
STEP.1:GENERAL INFORMATION
Na a of applicant (first middle initial, last) (please print) Daytime telephone number E-mail address
7g9ui �r41 /r'n> 31`7-0 °`(5 -3 �rA (ff1ye "c�STN 7
Address (number and sire Q City State L'
`7700 �re s>-DE C� F sffE 1,v ��3�
perk 4 1 &1 (a) (b)) Sex Height (R. In.) Weight (lbs_) Dale of birth (month, d year) Agee c�
Male 13 Female &I y d
X. one: rmit number (if newal) Check one (hat applies: Employee Permit 19 -20 year old Restricted Permit
Renewal riginal application Volunleer Permit
Name and address of permit premises where this permit is to be used (ifknown). L2 /V
It applying tar a Volunteer Permit, list the name and address of the not for profit organization. 1-?IoQ O k ��v c�
.:�STEP.2..BACKGRdUND QUESTIONS READCAREF.. PRIORTD'ANSUVERING
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 No please list the month, day, year, and location of yourconviction(s)
Yes KNo 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 4No 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 ?!f
Yes �00 yes, explain
Yes �J 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 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 o mit fficer may enter, inspect, and search the permit premises in which you work without a warrant and you must produce your
per on demand?
t7tYes ❑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?
s: STEP 3 19520 YEAR.OLD RESTRICTED FERMiT,::
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:`'FEE'ANb PAYMENT S "CH£buLE 'S
Type 900 3 Year Employee Permit(Fee $45.00)
Type 801 Volunteer Employee Permit (voltrntary services only for nonprofit organizations) (Fee $95.00)
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 6:`:SIGNATURE AND AFFIRMATION
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 or
this form is true and correct I understand that it is afLIM under Indiana law to misrepresent or falsify any portion of this applicatlon, and also realize I may be fined.
Signalur of ap nt Dale signed (month, day year)
ld 7
Owl Background Check No Owl owl owl No record on file
For Office Use Oni Eligible Ineligible
y -t Conviction Date(s) Eligible Date Initial Date
Revealed YES NO
s Plbscribebby State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 207 (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.
Payee II
J AX rchase Order No.
Terms
i�is� �N y��CGy Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
9 ev
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.
ALLOWED 20
IN SUM OF
ON A COUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
93 -CO 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
19
SiclnaturW.
(jvYl Sc/�.cr�
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund