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Home My WebLink About172879 05/27/2009 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1 f ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $90.00 CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 `o INDIANAPOLIS IN 46204 CHECK NUMBER: 172879 CHECK DATE: 5/27/2009 DEPARTMENT ACCOUNT PO NU MBER IN VOICE NUMBER AMOUNT DE SCRIPTION 1207 4355300 45.00 ORGANIZATION MEMBER 1207 4355300 2381 45.00 ORGANIZATION MEMBER r APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION 3 Year Employee Permit Type 900 302 W. Washington Street Rm. E114 7�r i 2 Year Volunteer Employee Permit -Type 809 Indianapolis, Indiana 46204 Employ Permit Section 317 232 -2455 are= 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 State Board of Accounts, 2005 aSTEP.I: GENERALS INFORMATION Name of 3 applicant (first, middle initial, last) (please print) Daytime telephone number E-mail I address Sf13� fjr"n PIRA. Cvi'%_ Address (number and street) City State Tip b7o fvet-43uz6il /"J 97 (,3c) Social Security Number (Mandatory per IC 4 -1 -8 -1 (a) (b)) Sex Height (11. in.) Weight (lbs.) Date of birth (month, day, year) Age ale 13 Female Check one: Permit number (if renewal) Check one that applies: 5 Employee Permit 11 19 -20 year old Restricted Permit Renewal Original application 13 Volunteer Permit Name and address cf permit premises where this permit Is to be used (il known). Q t IGSH IZ� [q6i� e U-b fy G-F If applying fora Volunteer Permit, list the name and address of the not for profit organization. 12120 V G j ��wh4 33�„*. k rF, d; tSTEP` 2�BIICKGROIJND, QUE5TIONS�= 'READ'.CAREFULLI'!;P.RIOR 70AN5WERING 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, Dyes dNO please list the month, day, year, and location of your convicilon(s) ❑Yes No Are you currently serving a sentence, Including any term of probation for operating a motor vehicle while intoxicated in Indiana or a similar y crime in another state? ❑Yes 0 Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue ?(Ifyes, you cannot have a permit unfit 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 No yes, explain v Yes VNo Have you had a drivers license in any other state in the last 19 years? If so, you must attach a copy of your driving record from that state. 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? es 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? lyes ❑No Do you know that the alcoholic beverage laws are part of the criminal code and are en €orceable by every law enforcement officer in the State of Indiana JZfVes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? a ai STEP;3. 19,20`;YEARiOLD RESTRICTED,:PERMIT ay t .d, 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:'SCHEbbilk ,�I Type 900 3 Year Employee Permit(Fee 45.00) y 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 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 or this form is true and correct. I understand that it is a telanv under Indiana law to misrepresent or falsify any portion of this application, and also realize 1 may be fined. Signature of applicant Date signed (month, day, year) OWI Background Check 1:3 No OWI owl OWI No record on file i :For Office Use Only h Eligible Ineligible Conviction Dale(s) Eligible Date Initial ffi Date Revealed YES NO APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION 3 Year Employee Permit -Type 900 302 W. Washington Street, Rm. E114 2 Year Volunteer Employee Permit Type 801 Indianapolis Indiana 46204 2 Year Restricted Permit T a 300 Employee Permit Section (317) 232 -2455 Ty 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 d j STEPJI GENERAQINFORM Name orl phcant (first, middle initial, last) (pl se print) Daytime telephone number E -ma' address r5 y-- bZ 5 b 1 l r1 u aa bL L Try) Address (number an street) Cit State Zip Le 5 I 4 r Via. eI �3� Social r Mandalo er 1 4-1-5-1 (a) (b)) Sex Height (ft in.) Check one: ermit number (ilrenewal) Check one that applies: [I Employee Permit El 19 -20 year old Restricted Permit O Renewal O iginal application Volunteer Permit N and addrref t premises whe his p r to usse (if k�nnoownn). in d H e n� ddre55 o h6t or pi�ft`efga��on O r Lo 0_A5 EA STEP 21xiB4CKGROIJND Qt1ESTIONS READ PRIOR 70 AtJSWERING 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, 13 yes U No please list the month, day, year, and location of your convictions) Yes 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 lo 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 ?lf Yes `i� o yes, explain 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 state. F 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? ff/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? Exes []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. lies ❑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 or €ainal Certified Server Training Certificate issued to you at your training session. Photocopies will not be accepted 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 Payme by mail may be made by money order, business check, or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. s `i ST 5 S IGNAfURErAND:A'FF,IRMQTION, p�_� ,ry 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 falsity any portion of this application, and also realize I may be fined. Sgnai pphcant /U Date si (month day, year) El owl El I owl I WI Background Check No Owl No record on file For Offlce Use Only Eligible Ineligible 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. Payee 7 Purchase Order No. 36, U• WtIS/ P Terms Date Due IF Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) z1h 90 �T'Gb M 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 -1.6. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF 90. ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 3 -ot) S, 06 bill(s) is (are) true and correct and that the a� S53 -c Z) S66 materials or services itemized thereon for which charge is made were ordered and received except 20 J S;ryr T Cost distribution ledger classification if Title [7! claim paid motor vehicle highway fund