174934 07/22/2009 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
t ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $45.00
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM El 14
INDIANAPOLIS IN 46204 CHECK NUMBER: 174934
CHECK DATE: 7/22/2009
DEP ARTMENT Y ACCOUNT PO NUMBER INVOICE NUMBER AM OUNT DESCRIPTION
1207 4355300 070909 45.00 ORGANIZATTON MEMBER
APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION
3 Year Employee Permit Type 900 302 W. Washington Street, Rm. E114
gI` 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:pwww.IN.gov /atc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by Stale Board of Accounts, 2005
STEP. 1. GENERAL INFORMATION
Name of applicant (first, middle initial, last) (please print) Daytime telephone number E -mail address
6 3 Q_ h A
Address (number and street) City r State Zip
/6 H r l� WP PIG( Ll
Social Securltv Number tUandatory perlC 4 -1 -8-1 (a) (b)) Sex Height (R. in.) Weight Fibs.) Date of bi h (month, day, year) Age
Male Female
Chec one: Permit number (if renewal) Check one that applies: ET Employee Permit 19 -20 year old Restricted Persil
Renewal 121 Original application 1 1 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.
STEP -2.` BACKGROUND' QUESTIONS REAU CAREFULLY: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 GNo please list the month, day, year, and location of your convictlon(s)
Yes ONo 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 irNo 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)
No yes, you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the last 5 years?if
Yes IpNo yes, explain
Yes WNo 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.
2 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?
U'Ves 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
pemlit on demand?
U's'es []No Do you know that the alcoholic beverage laws are part of the criminal code and are enforceable by every taw enforcement officer In the State of Indiana
17 Yes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEP 3.:19;20.YEAR.OLDRESTRICTED PERMIT'_
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
r STEP:4.'FEE-ANDPAYMENT:SCHEDULE
Type 900 3 Year Employee Permit(Fee $45.00)
Type 801 Volunteer Employee Permit (voluntary services only for nonproth 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.5:(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 felony under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be fined.
Signature of apQjraab Date signed (mon(fj, day year)
Background Check No OWI OWI OW 77 1 No record on file
For -Office Use Onl Eligible Ineligible
y`' Conviction Date(s) Eligible Date Initial Date
Revealed YES NO
Prescribed by' tate Boa[d_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.
Payee
Purchase Order No.
(1SZ1�j�nC{�Sy1 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
1111M r_0q_0q A �cov- I Pef VL�
Total L� •J� To
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. :_WAR'RANT NO.
C l -kOt ALLOWED 20
t- O
1 502� Lo IN SUM OF
Zo q
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #(TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
ID60 M -M -09 �3 -c .aD 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
ignatur
itle
Cost distribution ledger classification if
claim paid motor vehicle highway fund