174366 07/08/2009 CITY OF CARMEL, INDIANA VENDOR. 355486 Page 1 Of 1
ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $45.00
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114
•y oN o a., INDIANAPOLIS IN 46204 CHECK NUMBER: 174366
CHECK DATE: 7/8/2009
DEPARTMENT ACCOUNT PO NUMBER I NVOICE NUMBER AM OUNT DESCRIPTI
1207 ��4355300 45.00 ORGANIZATION MEMBER
APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL &TOBACCO COMMISSION
�1; 3 Year Employee Permit t� Type 900 302 W. Washington Street, Rm. E114
2 Year Volunteer Employee Permit -Type 801 Indianapolis, Indiana 46204
Employee Permit Section (317) 232 -2455
2 Year Restricted Permit Type 300 Web page: hftp: /www.IN.gov /atc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by Slate Board of Accounts, 2005
f „STEP 1 'GEIJERAL INF,ORMATION m m i
Name of applicant (first, fiddle initial, last) (please print) Daytime telephone number E -mail address
32 L (6 -3337 M', I�.O,�,�
Addrree (nu erraandd street)) Cit State p
Social ndat oer IC 4-1-el (a) (b)) I Sex Height (it. in.1 Weight (Ibs.) Dale of
Check one: Permit number (if renewal) Check one that applies: Employee Permit 19 -20 year old Restricted Permit
Renewal dginal application 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.
z P,2. BACKGROUND,GIUESTIONS, READ` C %KREFCiff PR1'dWhTO ANSWERING
Pease ave 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 ZNo list the month, day, year, and location of your conviction(s)
Yes ERiVo 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 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
N 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 _qN0 yes, explain
Yes .EkNo 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.
b'Yes 0 N 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?
.may res 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?
�Ye's ❑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.
1rYes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the 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 kf STEP 4 EEE AND'PAYMENT SCFIEDULE,
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.
a'SIGNATUREAND'IiFFIRMAfIONf s�.
„err
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.
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 applican Dat signed (month, day, year)
v Owl Background Check No Owl li Ib e Oeli Oble wl
13 No record on file
��ForOffice UseOnly' g 9
Conviction Date(s) Eligible Date Initial Date
y Revealed 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.
(�f Payee c� J_AcLLaNa u�' `-cA Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total �1
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.
D 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
C«
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
i at re
l Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund