168254 01/01/2009 CITY OF CARMEL, INDIANA VENDOR: I[/ ��bI y� Page 1 of 1
ONE CIVIC SQUARE CHECK AMOUNT:
CARf1AEE ,INDIANA 46032 CHECK NUMBER: 168264
CHECK DATE:
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
j
ti
.s 302 West Washington Street
IGCS Room Ell 4
STATE OF INDIANA Indianapolis, IN 46204
l �'t Telephone 317 t 232 -2430
ALcoFIOL AN1 TO BACCO L,01�1N1ISSION Fax 317 233 -6114
►r' vnm gov/atc
NOTICE OF RETURNED EMPLOYEE PERMIT APPLICATION
Your application is being rehu to you for the reason(s) indicated below. Please re- submit your
application with the requested i 1ormation attached to this notice. The Alcohol and Tobacco
Commission will make every effort to expedite your application once it has been received.
Complete current application fond
Failure to answer all questions
Social seciuity number required (will not she «T on your permit)
(1 Photocopy of your Social Security Card (Do not send the original)
your signatare
aalure.to pa3T pro f6 L—( Y._..� 45= 00= E>ulil "oyec_per� iic 3- year_ permit °effective 7 /1L08)s:_
$15.00 Volunteer permit
$30.00 19 -20 year old penuit
Failure to pay tlzc proper fee of $10:00 for reissue fee
Personal checks cannot be accepted
Please submit a certified check, cashiers check, company check, or money order.
Failure to pay outstanding taxes to the Indiana Department of Revenue (Sec question. regarding
taxes)
Department of Revenue tax protest (call 31 232 5977 option 91)
To receive a /restricted Permit (19 -20 year old), you must attach the ORIGINAL CERTIFICATE.
If you need to attend a Server Training Program, contact your District Excise Police Office to attend a,
scheduled training.
An applicant, is not entitled to a permit, if the applicmnt is serving a sentence for a conviction for
operating while intoxicated (QWI), including any term of probation or parole.
An,epplicant is not entitled to a pe,rrait, if the applicant has two unrelated convictions for OWI in
the ten (10) years immediately preceding the date of application, and it iaas been less than two years
since the completed their terra of probation or parole for the second OW1 conviction.
.An applicant is not entitled to a pe. if (ire applicant has at least three unrelated OW1
convictions in the ten (10) years immediately preceding the date of application.
If you believe that our itaforrnation is inaccurate, please submit your OF`F`ICIAL DRIVING RECORD fzotn
the Bureau of Motor Vehicles and proof that you have successfully completed your parole or probation.
Failure to provide a copy of your out -of -state driving record-
You &re no longer authorized to Rork on your receipt.
If you have any questions regarding this notice, please call the Bmtenders/Servers section at 317- 232^2455.
Thank you in advance for your cooperation.
(Formlevised 05/01/2008)
AN EQUAL OPPORTUNITY EMPLOYER
APPLO-;ATION FOR EMP E PERMIT INDIA
INDIANA ALCOHOL TOBACCO COMMISSION
t 2 lt". Em iloyee Perm' ype 900 302 W. Washington Street, Rm. El 14
2 Year Volunteer y� Indianapolis, Indiana 46204
ployee Permit -Type 801 V p
Employee Permit Section (317) 232 -2455
a f 2 Year Restr ed Permit Type 300 Web page: http: /twww.tN.govfatc
State For (R16111 -03) Hours: 8:00 am t0 4:00 pm EST
Appr d by State Board of Accounts, 2003
,STEP 1 GENERAL INFORMATION_
Name of applicant (first, middle initial, last) (please print) Daylime tel hone number E -mail address
1] veqf�t 317 7 Y) ZZ d✓an 8,- J
Address (number and stmet) City State Zip
��p� s CAP"E �i� v33
Social Securi Num ndato erlC 4-f -8-1 (a) (b)) Sex
Check one. Permit number (i( newai) Check one that applies; Employee Permit 19 -20 year old Restricted Permit
[I 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.
act Ic k/ le- C6Ur CG US
rrSTEPM BACKGROUNDpQUE$ TIONSj` REA{} G/ ?i12EFULLY _PRIOR;rO'i4NS1iVERINGt-
Have you ever been convicted of operating white Intoxicated in Indiana or of a similar charge in any other state? (if yes, please list the
❑Yes 0No month, day, year, and location of your conviction(s)
❑Yes qV N D Are you currently serving a sentence, including any term of probation for operating while intoxicated in Indiana or a similar crime in
another state?
❑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)
,p. 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 I ff yes, explain
[]Yes No 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.
IpYes ❑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?
Qfes ONO 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?
a
STEP 3 19�20"YEAR,OLD RESTRICTED 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.
r 'r STEP 4, ;FE'AN�,P,AYMEIJTSGHEDULE
Type 900 2 Year Employee Permit (Fee §30.00)
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.
7P-' 5� SIGNAfokk
z v
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 fel under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be
fined.
Sig re ofpplican
lr y Date signed (month, day, ear)
Zov
a 3 OWI Background Check E1 No OWI OWI ON Eligible Ineligible No record on fie
For Y Offce k Use'On(y;
x 4 Conviction Date(s) Eligible Date Initial &Date
.''r Revealed YES 11 NO
APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL &TOBACCO COMMISSION
i u 2 Employee Permit Type 900 302 W. Washington Street, Rm. E114
Z 2 Year Volunteer Employee Permit Type 801 Indianapolis, Indiana 48204
2 Year Restricted Permit Type 300 Employee Permit Section (317) 232 -2455
010 Web page: http: /Avww.IN.gov /atc
State Form 43 (R161 11 -03) Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2003
Name 91 applicant (first, middle radial, I t) (please print) Daytime telephone number E -mail address
1 i
Address (number and street) City Slate Zip
414 bi& EfZ X Z 5 ClUt tM 1 N nth, day, Lf(,90.3 j
Social Securi Number (Mandatory per IC 4 -1 -8-1 (a) (b)) Sex Height (R. in.) Weight (lbs.) Date of birth (
Check one: Permit number (if renewal) Check one that applies: Em to Employee Permit
P y 19 -20 year old Restricted Permit
El 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,
fZ=K htlZf G. u 2 I ZD (SXOOKSllffZE i'Azt< -vA l Cr -X011 t_ /N H�d3
:'G STEP. 2 BACKGROUNGI!QfIESTIONS REAQ,CAREF,ULCY PRIORTO A ]INS tER1NGF
Have you ever been convicted of operating while Intoxicated In Indiana or of a similar charge in any other state? (!f yes, please list the
❑Yes iNo month, day, year, and location of your conviction(s)
❑Yes No Are you currently serving a sentence, including any term of probation for operating while intoxicated in Indiana or a similar crime in
another state?
[]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 rO No 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.
Aed
Yes L 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?
X Yes ❑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?
K Yes No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEP3: 19 2ff,;YEAR'OL� RESTRICTED''PERMITr.
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.t.FEErANI];RAYM£NT;SCHEOULE
Type 900 2 Year Employee Permit (Fee $30.00)
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.
k
STEP 5 .ISIGNATURlr'ANQ AFFIRMATION x
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 felony under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be
fined.
Signature of applicant Date signed (m nth, day, year)
Z f !Ur
Owl Background Check No OWI owl OWI
f Eligible Ineligible No record on file
Far Office Use Ofily
h Conviction Date(s) Eligible Date Initial &Date
Revealed 13 YES NO
Prescribed by State 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.
�i
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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 -1.5.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
SUM OF
GZ tAj ff,C>I C
ON ACCOUNT OF APPROPRIATION FOR
I9Z
Board Members
PO# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. 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
Cost distribution ledger classification if
claim paid motor vehicle highway fund