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Home My WebLink About173374 06/10/2009 CITY OF CARMEL VENDOR: 355436 INDIANA Page 1 of 1 ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $135.00 u CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 INDIANAPOLIS IN 46204 CHECK NUMBER: 173374 CHECK DATE: 6/10/2009 DEPARTMENT ACCOUNT PO N UMBER INVOICE NUMBE AMOUNT D ESCRI P TION 1207 4355300 -_T___ 135.00 ORGANIZATION MEMBER APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION 3 Year Employee Permit Type 900 302 W. Washington Street, Rm. E1 14 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:/Avww,IN.gov/atc Hours: 8:00 am to 4:00 pm EST State Form 43 Approved by State Board of Accounts, 2005 STEP 7 Name gtapplicanl (171 1, middle let, last) (please print) Daytime telephone number E-mall address A SWe Address (number street) clti� _fZ__/ Zip I soaal Securit Number IC 4-1-9-1 (a) (b)) Sex Height (ft. in.) Weight (lbs.) Date of birth (month, day', year) Permit Check one' Permit number (If renewal) JCheck one that applies: OEmployee Permit 13 19 -20 year old Restricted Permit Renewal 113 Original application 13 Volunteer Permit r and address o permit premises where this permit Is to be used (1/known). /IXO i If Volunteer Permit, list the name and address of the not for profit o anize rg appl ying for a V tion. 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) –WNo Are you currently serving a sentence. including any term of probation for o perating a motor vehicle while Intoxicated In Indiana or a sim liar Yes crime In another state? Yes No Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(Ifyes, you cannot have a permit until all liabilities have been pala) Have you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the last 5 years?ff Yes E2j1N/o' yes, explain r t Yes ofI 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 fro that s tate EZ/Y.S 0-Do you know that it is a Class B Misdemeanor, punishable by up to 6 months In (all and a $1,000 fine, for knowingly serving an Intoxicated person? Yes ONo 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 an demand? es ❑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' Ye ❑No IDo you understand that this employee permit Is yours and that your employer Is only allowed to copy the permit? 77 To receive a Restricted Employee Permit, you must attachthe original Certified Server Training Certificate Issued to you at your training session. Photocopies will not be accepted. 7 77 7, S Woii t. *tkiA 0A Type 900 3 Year Employee Perrntt(Fee $45.00) Type 801 Volunteer Employee Peffnit(voluntary services only for nonprofit organizations) (Fee $15.00) Type 300 2 Year Restricted Permit (Fee $30.00) You may work on your receipt for only 30 days Payment by mail may he made by money order, business check, or certified check. 00 NOT SEND CASH OR PERSONAL CHECKS. ST P;5 ,SIGNATURE AND '77777777= I certify that2l was cojnpleted by myself. I affirm under penalties of perjury that I am at least 19 years of age and that all Information provided on this I i a and correct. I un rs land that it is afC= under Indlana law to misrepresent or falsify any portion of this application, and also realize I may be fined. Signa2%4applicanL( Date signed (month, day, year) V: 0 1 Background Check No Owl owl owl 0 No record on file Eligible Ineligible n Date(s) Eligible Date Initial Date Convicti YES NO APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL &TOBACCO COMMISSION 3 Year Employee Permit Type 900 302 W. Washington Street, Rm. Ell 14 Indianapoils, Indiana 46204 2 Year Volunteer Employee Permit -Type 801 Employee Permit Section (317) 232-2455 oiw 2 Year Restricted Permit Type 300 Web page: http:1hvww.IN.goviatc Hours: 8:00 am to 4:00 pro EST State Form 43 Approved by State Board of Accounts. 2005 WFORM—A. Na (applicani (first, middle Inilial,_ last) (please print) Daytime telephone number E-mail address r9ag _7 -SO de_q r; in,6 rr, to(T- 2 r 6 Eq q e- State Zip Address (number and street) city C I A I 4�,633 1$Q W k R.S k DC 7 Check one: 7ml�- Permit number (1fronewei) Check one that applies: E3 Employee Permit D 19 -20 year old Restricted Permit OlRer,Lwal )QOdgl a—lappli-c--ation 13 Volunteer Permit (If Na" and address of permit preMIS06 where MIS permit Is to be used ffknown). nu If applying for a Volunteer Permit, list the name and address of the not for profit organization. 6 ,STER.' 1 1 7,. 04100 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, 9 Indiana No please list the month, day, year, and location of your conviction(s) a Are you currently serving a sentence, Including any term of probation for operating a motor vehicle while Intoxicated in or a similar crime In another state? Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(Ifyes, you cannot have a Permit until Yes �No all liabilities have been Palo) Have you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the last 5 years7lf Yes Yallo yes, explain Cl Yes *o Have you had a drivers license in any other state In the last 10 years7 if so yo u must attach a copy of your driving record from that state. K Yes ❑No Do you know that it is a Class S Misdemeanor, punishable by up to 6 months In ]all and a $1,000 fine, for knowingly serving an intoxicated person? 0 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 Yes ON permit on demand? Y es ❑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' ❑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 attachthe orinin Certified Server Training Certificate Issued to you at your training session. Photocopies will not be accep STE P 4 Type 900 3 Year Employee Permit (Fee $45.00) Type 801 Volunteer Employee Permit (voluntary services only for nonprofit organizations) (Fee 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. 71 7 7 7 7 -7 I certify that this application was completed by myself. I aMffn under penalties of perjury that I am at least 19 years of age and that all Information provided orl 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 (month day, year) owl Background Check No OWl owl Owr No record on file Eligible Ineligible 10 0,11 Conviction Da Eligible Date I nitia l Date Data(s) Revealed YES NO APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL B, TOBACCO COMMISSION 302 W. Washington Street, Rm. E114 y 3 Year Employee Permit -Type 900 Indianapolis, Indiana 46204 2 Year Volunteer Employee Permit -Type 801 Employee Permtt Section (317) 232 -2455 Web page: htip: /www.IN.gov /atc t 2 Year Restricted Permit Type 300 Hours: 8:00 am to 4:00 pm EST State Form 43 Approved by State Board of Accounts, 2005 13' 4 F S t €r )I. t li u k V411T M 'r" I! Da Imetele hone number E -mail address Name of app t (first, middle frit im, las lease print) t elephone V p we J S Add amber d at) f CII Slate Zip SL Social WpA or lC 4 -1-6.1 (a) (b)) i s Height (R. In.) l Weight (Ihs.J jDale of birt (month, day, y e ar) Age Male Female Check one. Permit number (il renawa!) Check one that applies: Employee Permit 19 -2 year old Restricted Permit Renewal 'gloat application Volunteer Permit Name and ad Tess of permit premises where this permit is to be used (It known). I applying for a Volunteer Permll hs1 the name and address pf the not for profit organ zallon f!4 i 1 17 :ill)�al itl(IEi 1l�it.'Ifitli r h �;�1� �i,�1. U IMF ,�s�Ii11 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, Oyes please 11st the month, day, year, and location of your convlctlon(s) Are you currently serving a sentence, Including any tens of probation for operating a motor vehicle while Intoxicated in Indiana or a similar ❑Yes o crime In another state? Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue ?(1 yes, you cannot have a permit until 0 Yes N all you 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 years7lf ❑Yes o yes, explain 0 Yes 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 stale. Yes ONO Do you know that N is a Class B Misdemeanor, punishable by up to 6 months in jail and a $1,000 fine, for knowingly serving an intoxicated person? 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 es ONO permit on demand? 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 U(l �es ONO Do you understand that this employee permit Is yours and that your employer is only allowed to copy the permit? y =acca t t� i. ted Employee Permit, you must attach oriainal Certified Server Training Certificate Issued to you at your training session. Photocopies u! r 3 r r r I iur a d, h r ri81' ��.k�f�t�r�r�` '�r��i�>r 3�u Type goo 3 Year Employee Permil(Fee $45.00) Type Sot Volunteer Employee permit(vofuntary services only tornonprofit oruanizations) (Fee $15.00) Type 300 -2 Year Restricted Permit(Fee $30.00) You may work on your receipt for only 30 days Payment by mall may be made by money order, business check, or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. 'd 11 41 Ilk, Ir 711 i ii I certify that this application was completed by myself. l affirm under penalties of perjury that 1 am at least 10 years of age and that all information provided o this form Is true and correct. I understand that it is a fe n under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be fined. Date signed (month, day, year) Signature of a 1' sl s 13 owl O No record on file OWI Background Check No OV Eli ible Ineligible Eligible Dale initial Date m pie i Conviction Dates) Revealed YES NO Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (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 ni R /n :Z; v ir�,r.,` Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 26 1 _T 1 Ofi lQku Hal O 0 F1L f l -l- S, UU 6 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. ALLOWED 20 �l�it� -,c)A ��'U,�1/� �•l �i�.� t >e� �o'�- ss;� IN SUM OF ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT /TITLE AMOUNT DEPT. I hereby certify that the attached invoices or -G-0 s166 bill(s) is (are) true and correct and that the S:6D materials or services itemized thereon for l 0'7 S which charge is made were ordered and received except 20 irature Cost distribution ledger classification if Title claim paid motor vehicle highway fund