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Home My WebLink About172658 05/20/2009 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1 ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMMM CK AMOUNT: $90.00 CARMEL, INDIANA 46032 302 W WASHINGTON STREET ROOM E114 CHE INDIANAPOLIS IN 46204 as CHECK NUMBER: 172658 CHECK DATE: 5!2012009 DEPARTMEN ACCO PO NU MBER INVO NUMBER A DESC 1207 4355300 90.00 CALHOUN /GLENTZER k� 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 r� Employee Permit Section (317) 232 2455 re e 2 Year Restricted Permit Type 300 Web page: http:Ifwww.IN.gov /atc State Form 43 Hours: 8:00 am to 4:00 pm EST 4 Approved by State Board of Accounts, 2005 STEP 1'.,GENERAL INF,ORMATIONa. Name of applicant (first, middle initial, Iasi) (please print) Daytime telephone number E -mail address 1 enrlZe� 312 -MLI 6 4 k A Cial,c:v/`'l Address (number and street) City State Zi Ces4 ,)o r e l) _).V 735 Social Securit Number Mandato er IC 4 -1 -8 -1 (a) (b)) Seexx Height (R. in.) Weight (Ibs.) Renewal 13 Original application 1 13 Volunteer Permit Name and address of permit premises where this permit is to be used (if known). V rOO Sh I f le- 6 Cl tfb j7i /1 If applying for a Volunteer Permit, list The name and address of the not for profit organization. I t71 Q (vOl�f 1 1ri< f i`�.� �1j8'iC J qp Q3 r zf�. t ,STEP,2,BACKGROUNf),r,QUEST'11 h „CAREFULLVsPRIOR Tr];ANS1NEfZING 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 M please list the month, day, year, and location of your convfct)on(s) Yes GIN. 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 dNo 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 1 Yes No 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. E 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? E 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? Yes []No Do you know that the alcoholic beverage taws are part of the criminat code and are enforceable by every law enforcement officer in the State of Indiana Yes []No 1 130 you understand that this employee permit is yours and that your employer is only allowed to copy the permit? ti a� e 3''194cYEAkOL'D Rit T ldT MI EDxPERT -•r f, a 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 Type 900 3 Year Employee Permit(Fee $45.00) Type 801 -Volunteer Employee Permit(voluntary services only for nonprofit organizations) (Fee 515.00) Type 300 -2 Year Restricted Permit (Fee 530.00) 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. ,..g� i,. -wit ✓Fib. y 3 -_k_3 .�..w.. s5'._ SIGNA7URE�AND AF ,K STEP. 5.. FIRMATION aa 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 applicant Date signed month, d year) a� Q J, s OWI Background Check No OWl OWI owl No record on file For Office Use "Only Eligible Ineligible Conviction Dates) Eligible Date a initial Date Revealed OYES NO APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION r: 2 Year Employee Permit -Type 900 302 W. Washington street, Rm. El 14 2 Year Volunteer Employee Permit Type 801 Indianapolis, Indiana 46204 2 Year Restricted Permit -Type 300 Employee Permit Section (317) 232 -2455 —lain We State Farm 43 (RIB 111-03) Ho page: http: /Avww.IN,gov /atc Approved by State Board of Accounts, 2003 urs: 8:00 am to 4;00 pm EST k (P P'� Day time a NfAFIQN ¢t�STP�1 oG MERA 1NF,- Name or ppli'ant (first, middle initial, last lease not hone number Address -mail address hale Cal ov 37- 2 Calhovv� 13 ail cov>h IV( (number and street} City State I err Ive l+� pan VIS I N 4 Social Security Nu r(Mandatory perk 4 -1 -8.1 (a) (b)) li ex Hei ht (R. in.) Weight (tbs.) Date of birth (month, Check one: Permit number (if renewal) Check one that applies: Employee Permit E] 19 -20 year old Restricted Pe El L rmit Renewal Original application Volunteer Permit Name and address of permit premises where this permit is to be used (if known). It applying for a Volunteer Permit, list the name and address of the not for profit organization. ►2120 �6c> sv( re kw Carm�� IN 4� 633 $14�ii'�,rlA,_._ t �IAD ,r,`A'_FtEF,UL`1X,('t31,OF.TQ ANB.WE'1311.`lt" E, �A` r 3 Have you ever been convicted of operating while in toxl_ated in Indiana or c: a similar charge In any other state? (lf yes, please list the ❑Yes NO month, day, year, and location ofyourconvlctlon(s) []Yes ONO Are you currently serving a sentence, including any term of probation for operating while Intoxicated in Indiana or a similar crime in another state? [1Yes N Np 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? ❑Yes P No If yes, explain (3Yes ❑No Have you ever had a drivers license In any other state? If so, you must attach a copy of your driving record from that state. Les zlyes ❑No Do you know that it is a Class 8 Misdemeanor, punishable by up to B months in )ail and a $1,000 fine, for knowingly serving an intoxicated person? ❑No Do you know that an excise officer may enter, inspect, and search the permit premises in which you work without a wan ant and you must produce your permit on demand? ❑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 Stale of Indiana? No Do you understand that this employee permit Is yours and that your employer is only allowed to copy the permit? a� t `5TEP'3�s15, 2D „Y.EARFpt l] R @5TRiCTEi)'PERIyIIT r To receive a Restricted Employee Permit, you must attach the original Certified Server Training Certificate Issued to you at your training session. Photocopies will not be accepted v,SF i? 4 FED A MD PAYMENT SCHED.ULI= 7 Type 900 2 Year Employee Permit (Fee s30.00) 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. 00 NOT SEND CASH OR PERSONAL CHECKS. b.Y. Ohl rr: 1 o; �1.F f s. .a iI ^�..�f M ..t.�.s..: �jF1A7U:pIVq ,FIRNtAT1ON„ r `3 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 fefonv under Indiana law to misrepresent or falsity any portion of this application, and also realize I may be fined. Signature of applicant Date signed (mant dey year 2r p OWI Background Check No OWI Q owl El OW Eli ible Ineli ible 11 No record on file FOF Q#Ftei 115�dfi1 Conviction Dates) Eligible Date Initial 8 Date y Revealed YES NO Prescri"d A State �o�ard 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 614.0 b.CJ eee--, 0"4,j Purchase Order No. n 6tI V Terms ►�!?'�ra �/<oaC� Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 6 l Lf5' Total '2'5"0 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. w. ALLOWED 20 IN SUM OF ON ACCOUNT OF APPROPRIATION FOR 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 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund