HomeMy WebLinkAbout170904 04/16/2009 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM
CARMEL, INDIANA 46032 CHECK AMOUNT: $45.00
ror r o CHECK NUMBER: 170904
CHECK DATE: 411612009
DEPARTMENT ACCOU PO NUMBE INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 45.00 ORGANIZATION MEMBER
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APPLICATION FOR EMPLOYEE PERMIT
INDIANA ALCOHOL &TOBACCO COMMISSION
3 Year Employee Permit Type 900 302 W. Washington Street, Rm. El 14
2 Year Volunteer Employee Permit Type 801 Indianapoiis, Indiana 46204
Employee Permit Section (317) 232 -2455
2 Year Restricted Permit -Type 300 Web page: http: /(www,IN.gov /atc
Scale Form 43 Hours: 8!00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
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I ENERAL11Nl=(}RMA',i ON 1try)i °r t !t)ttg i r `,,i i ..:jc I r t{ ,�t s :r r
Name of applicant (first,
middle initial, last) (please print) ID aytime telephone number E-mail address
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Address (number and street) City State Zip
Social Security Number
Permit number (if renewal) Check one that applies: 1Y€mpioyee Permit 19 year old Restricted Permit
Renewal D-1<9inat application Volunteer Permit
Name and address of permit premises where this permit is to be used (ifknown). i31 2C%i45/Fi1ZG n �n
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If applying for a Volunteer Permit, list the name and address of the not for profit organization.
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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 L9 No please list the month, day, year, and location of your conviction(s)
CD Yes No Are you currently serving a sentence, Including any term of probation for operating a motor vehicle while intoxicated in Indiana Ora similar
crime in another state?
Yes ZN. 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)
0 Yes 7N. 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
Yes 121 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.
Y es ❑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?
I ❑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
perms 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
es ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
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4S TEP_ 3, 19�2QYEARQL 'DIRE37RICTED },,FERMETk'
To receive a Restricted Employee Permit, you must attach original Certified Server Training Certificate issued to you at your training session. Photocopies
wiii not be accepted p
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�r AYM�NT5CHEDULE ,.hail`1r�i31kt�al�E.�. cif, tf1�3�n, �tt�t,,(( �1�: ��IZ :+7��ts:1�a�;Eir4E�f�,l:�l>;
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 $90.00)
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.
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t .a. I,t t v.:ir.,,.,I1cSTEP 6.@SIGNATUREANDAFFtRMAT10N, ,trS a �tjt3Gl:��x S j, riz,,tr
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 felony under Indiana law to misrepresent or falsify any portion of this application, and also realize I may be fined.
Srgnatur of nt Date signed onth, y, y ar)
rl') 1 OWI Back round Gheck No OWI OWI El OWI
No record on file
For Officmuselanlyr� g Eligible Ineligible
r a Conviction Dale(s) Eligible Date Initial Date
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l y Revealed 0 YES 13 NO
Press 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
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i- Terms
�,y 416,20 el Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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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
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1
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ON ACCOUNT OF APPROPRIATION FOR
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Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
rs7g_ 6 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
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or 4air
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund