170200 03/24/2009 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
I ±0 ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM
R�VIEL, INDIANA 46032 CHECK AMOUNT: $135.00
CA
CHECK NUMBER: 170200
CHECK DATE: 3/24/2009
DEPARTMENT ACCOUN PO NUMBER INV OICE NU MBER AMOUNT DESCRIPTION m
1207 4358300 135.00 LICENSES
a APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION
3 Year Employee Permit Type 900 302 W. Washington Street, Rm. E114
3 2 Year Volunteer Employee Permit -Type 801 Indianapolis, Indiana 46204
Employee Permit Section (317) 232 -2455
2 Year Restricted Permit -Type 300 Web page: http: /www.IN.gov late
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
STERi1;tGENtkALJNFRMA
QTIaN
Name of applicant firs) middle inrhal, last) (please print) Daytime telephone number E -mail address
Address (number and street) City State Zip
Social
number (if renewal) Check one that applies: Employee Permit 0 19 -20 year old Restricted Permit
Renewal l.lTOriginal application I Ia Volunteer Permit
Name and address of permit premises where this permit is to be used (it known). '?,i2v0 jC Ski O •i S v
kt applying for a Volunteer Permit, list the name and address of the not for profit organization. j �e_/ 1A) y� j
�CSTEP�BACKGROI] ifDC1UE5TIQNS, ttEAt] C4FlEFULLI !.PRIOR:TOANSWERiNG, „n,. I
Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge in any other state ?(!f yes
❑Yes let NO please list the month, day, year, and location of your convictions)
Yes ONO 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 two 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 No yes, explain
Yes o 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.
t��i ees ❑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?
EK. [:]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?
L�KY�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
tlYYes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
STEP 3 .19 =20 YEAR,OLU RESTf21CTED
To receive a Restricted Employee Permit, you must attach oricrinal Certified Server Training Certificate issued to you at your training session. Photocopies
will not be accepted
;.7 te a.
Type 900 -3 Year Employee Permit (Fee $45.00)
Type 801 Volunteer Employee Permit (volun(ary services only for nonprofit organizations) (Fee $15.00)
Type 300 -2 Year Restricted PenTill ee.$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.
NxSTEP AND AFFIRMAT }ON r
1 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 o (;earl Date signed (month, day, year)
OWI Background Check 11 No OWI 13 OWI OWi
Eligible Ineligible No record on file
For Office Use, Qnly'
Conviction Date(s) Eligible Date Initial &Date
x Revealed YES NO
APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION
2 Year Employee Permit Type 900 302 W. Washington Street, Rm. E1
2 Year Volunteer Employee Permit Type 801 Indianapolis, Indiana 46204
Employee Permit Section (317) 232 -24
2 Year Restricted Permit Type 300 55
-latd Web page: httpJlwww.IN.govlatc
Stale Form 43 (Riff f 11 -03) Hours: 8:00 am to 4 :00 pm EST
Approved by State Board of Accounts, 2003
STEP 1. GENERAL
[A me of applicant (first, middle initial, last) (please print) Daytime telephone number E -mail address
(number and street) City State -1 6c r p
r��
So ��r •r�L S &03 Social Security Number Man ryperJC 4 &i (a) (b)) Sex Height (R. fn.) Weight (Ibs.) Date of birth (month, day, yea o e
la
Male
r Jrr d 9
Female
P6pnnii number (if renewal) Check one that applies:
mployee Pemot 19 0 year old Restrtded Permit
Renewal Original application El Volunteer Permit
Name and address of permit premises where this permit is to be used (rf known). If applying for a Volunteer hermit list the name and address of the not for profit organization.
21 15 /3 C fy
STEP Y RACKGRO ND QUESTIONS READ CAREFULLY PRIOR.TO ANSWERING
Have you ever been convicted of operating while intoxicated in Indiana or of a similar charge In any other state? (If yes, please list the
[]yes No month, day, year, and location of your conviction(s)
❑Yes No Are you currently serving a sentence, Including any term of probation for operating 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 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 I �q No If yes, explain
❑Yes V[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.
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?
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 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?
N k
STEP 3.19 -20 YEAR OLD RESTRICTED' PERMIT
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 acce ted.
W.
STEP 4.; PAYMENTSCHI`Df1LE
rPaymentby Year Employee Permit (Fee $30.00)
lunteer Employee Permit (voluntary services only for nonprofit organizations) (Fee $15 -00)
ear Restricted Permit (Fee $30.00)
on your receipt for only 30 days
ail may be made by money order, business check, or c ertified check. DO NOT SEND CASH OR PERS=CHECKS.
STEP. 5. SIGNATURE AND AFFIRMATION
I certify that this application was co leted by myself. 1 affirm under penalties of perjury that I am at least 19 years of age and that all information provided
on this form is correct I u erstand that i(is a felony under Indiana law to misrepresent or falsify any portion of this application, and also realize I maybe
fined.
Signature of appli t Dale signe (monf da year)
Owl Background Check No Owl OWI OVT
Eligible Ineligible No record on file
FOr Office USe'Only Conviction Dale(s) Eligible Date
Revealed 0 YES NO Initial &Date
APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL TOBACCO COMMISSION
3 Year Employee Permit -Type 900 302 W. Washington Street, Rm. E114
f
2 Year Volunteer Employee Permit -Type 801 Indianapolis, Indiana 46204
Employee Permit Section (317) 232 2455
We 2 Year Restricted Permit Type 300 Web page: http•l /www.IN.gov /atc
State Form 43 Hours: 8:00 am to 4:00 pm EST
Approved by State Board of Accounts, 2005
`GENERAL "'INt =,ORMATION
Name of applicant (first, middle initial, last) (please print) Daytime telephone number E -mail ddress .L,
.3i 363 S 7 C&M LQ 5 f:• /r
Address (number and street) City State Zip
Social Securit ertC 4 -1 -8 -1 (a) (b Sex Heir htilt Weight (tbs.) Date of birth day, yeas Age
Male 11
Ch ermit number (i /renewal) Check one that applies: PW Permit 0 19 -20 year old Restricted Permit
E3 Renewal 0 original application 13 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.
STEP 2 BACKGROUNI ];QUESTIONS'- '_READ;CAREFUL`LY PRIpR'.TO ANSWERING,
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 No please list the month, day, year, and location of yourconviction(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
crime in another state?
Yes Ito 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 M4. yes, explain
Yes IX. Have you had a drivers fieense in any other state in the last 10 years? If so, you must attach a copy of your driving record from that state.
77 ❑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?
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?
ch 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.
Yes ❑No Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
ka. u_? r, STEP 319= 20aYEAR,OLD RES7RICTED.at?ERMIT,
To receive a Restricted Employee Permit, you must atlach orirLinal Certified Server Training Certificate issued to you at your training session. Photocopies
will not be accepted
r, cF r "STEP 4 °FEE AND'PAYMENT_SCHEL3UE„ z
Type 900 -3 Year Employee Permit (Fee $45.00)
Type 601 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.
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 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 I'm ont day, year)
round Check No OWI 13 OWI OWI
OWI Background No record on file
For Office Use Onl Eligible Ineligible
y Conviction Date(s) Eligible Date Initial Date
Revealed YES NO
Prescribed by State Board N— counts 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.
l� Pay
0 49 4"e'() 04M I P l j Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice( or bill(s))
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
/3S
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
/1 �3 /3-a` 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