219774 05/07/2013 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMM
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK AMOUNT: $45.00
INDIANAPOLIS IN 46204 CHECK NUMBER: 219774
CHECK DATE: 5/7/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 S. DEMPSEY 45 . 00 ORGANIZATION & MEMBER
•"'� APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL&TOBACCO COMMISSION
!k:_ 3 Year Employee Permit-Type 900 302 W.Washington Street,Rm.E114
3mr Indianapolis,Indiana 46204
2 Year Volunteer Employee Permit-Type 801 Employee Permit Section(317)232-2455
mere 2 Year Restricted Permit-Type 300 Web page:http:/Avww.IN.gov/atc
State Form 43 Hours:8:00 am to 4:00 pm EST
Approved by State Board of Accounts,2005
,:,__°-STEP 1:GENERAL INFORMATION - -' �
Name of applicant(first,middle initial,last)(please print) Daytime telephone number E-mail address
L U�ri1 e'i C3.1 3` 9 5glem e pqrno i I. coirl
Address(number and street) City State Zip
�qar� Cavendish wo�cl Indi�.nc�po<<s 1 N �{1e22�
Social Security Number(Mandatory per IC 4-1-8-1(a)(b)) Sex Height(ft in.)r Weight(lbs.) Date of birth(m nth,day, ear) JAge
3a�-4 Z -3 8(r✓9 ❑ Male .� Female
51 111 i2IZgIIg3� Z3
Check one: Permit number(rf renewal) Check one that applies: _Z7 Employee Permit ❑ 19-20 year old Restricted Permit .
❑Renewal ZDriginal application 1 1 ❑ Volunteer Permit
Name and address of permit premises where this permit is to be used(if known).
If applying for a Volunteer PermiL list the name and address of the not for profit organization.
• ,.>:.:STEP:2:BAGKGRQUN ,...__. .__..:-...- .....:.__ .-.,. ..--•- - - -- ........-.... .....:.............. .... .... ..
_ _ Q'flUESTIONS=:READ�CAREF,ULLYiPRIOR-TO'ANSWERiNCr�, ,-
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,
es JNo please list the month,day,year,and location of your conviction(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 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 ilabilitles 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?/f
❑Yes J<No yes explain
❑Yes Ao 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.
Ayes ❑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?
Xes ❑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?
STEP 3.:19=20:YEAR OLD?RESTRICTED PERMIT ;-;
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.
,. . . P,:4i'FEE•AND;PAYMENTSCHE�ULE
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 Pernit(Fee$30.00)
You may work can 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
I certify that this application was completed by myself. I affirm under penalties of perjury that 1 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 felony under Indiana law to misrepresent or falsify any portion of this application,and also realize I may be fined.
Signature of applicant Date sign (month, ay,year)
(),670Z 2013
OWI Background C ec ❑ No OWI ❑ OWI ❑ OWI ❑ No record on file
For Offfce:Use:.Ooly. Eligible Ineligible
Initial&Date
Conviction Date(s) Eligible Date Revealed 0 YES ❑ NO
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Alcohol & Tobacco Commission
IN SUM OF $
302 West Washington Street, Room E 114
Indianapolis, IN 46204
$45.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1207 I Sarah Dempsey I 43-553.00 I $45.00 1 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
Friday, May 03, 2013
Director, Brooksh a Golf Club
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
05/02/13 I Sarah Dempsey I Permit I $45.00
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