177257 09/15/2009 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
0 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: 177257
a
CHECK DATE: 9/15/2009
D EPAR TM ENT ACCOUN PO NUMB INVOICE NUMB AMOU DESC
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. E114
Indianapolis, Indiana 46204
2 Year Volunteer Employee Permit Type 801
Employee Permit Section (317) 232 2455
re�e 2 Year Restricted Permit Type 300 Web page: http: /www.IN.gov /atc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
':tTEO 1. dENERALJNFORMATION
Name of applicant (first, middle initial, last) (please print) Daytime telephone number E -mail address
%O S. \�a�c� 1(05 ZIS 1303 �>c
Address (number and street) Cites Stale Zip
5M-) Sco}� -Say Ck tanc.(�o�t5 1 4GZSN
Social Security Number o per IC 4 -1.8-1 (a) (b)) Sex Height (N. in.) Weight (lbs.) Date of bi h (mom day, year) Age
Male 13 Female
Check one: Permit number (drenewal) Check one that applies: Employee Permit 19 -20 year old Restricted Permit
Renewal I]rOriginal application Volunteer Permit o
r me and address of permit premises where this permit is to be used (ifknown). Lao (�(pp�5�� rC W applying for a Volunteer Permit, list the name and address of the not for profit organization. Co. C f� I-/J C/(0033
STEP 2: BACKGROUND'= QUESTIONS READ CAREFULLY:PRIOR TO ANSWERING;?
,,J 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 your conviction(s)
0 Yes WN. 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 tdNo 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 ?If
Yes [Nf No yes, explain
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.
LJYes ❑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 [I 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?
M 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
[dyes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEP 3.'19- .YEAR.
OLD'RESTRICTED
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'AND'PAYMENT'SGHEDULE
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.
STEP:S.: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 o rl
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.
Signatur pplicanl Date signed month, day, year)
Q z 09
OWI Background Check 1:1 No OWI OWI 11 O I No record on file
i' Eligible Ineligible
For Offlce On ly Conviction Date(s) Eligible Date Initial Date
Revealed YES NO
�,1
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 7995)
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
q l')�/��/�l� C am I i Purchase Order No.
km F//�L Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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
VOUCHER NO. WARRANT NO.
n ALLOWED 20
IN SUM OF
&/a
ON ACCOUNT OF APPROPRIATION FOR
6
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
s3�. 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
ignatu e
'title
Cost distribution ledger classification if
claim paid motor vehicle highway fund