224536 09/25/2013 »,f CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMM
CHECK AMOUNT: $45.00
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114
INDIANAPOLIS IN 46204 CHECK NUMBER: 224536
CHECK DATE: 9/2512013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 VASIL 45 . 00 ORGANIZATION & MEMBER
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 Indianapolis.Indiana 46204
late 2 Year Restricted Permit-Type 300 Employee Permit Section(317)232-2455
Web page:hftp:ltwww.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, (please print) Daytime telephone number E-mail address
.j-10 -311()
Address(number and street) city State 1zlp
iq 000-AT C- nAl H( 033
Social Security Number(Mandatory per IC 414-1(a)(b)) Sex Height(fl.in.) Weight(lbs.) Date of birth(month,day;year) Age
113 Mate Female
Check one: [Permit number(d renewal) Check one that applies: Employee Permit ❑ 19-20 year old Restricted Permit
5 13 Volunteer Permit
)d'' Renewal C30dginalapplicaflon 0 115
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.
--Ly,'70916 T
,—�STEP2ZBAC. GIR UIEtT Q-ANSWEIRik
Have you ever been convicted of operating a motor vehicle while Intoxicated in Indiana or of a similar charge in any other state?(Ifyes,
❑Yes ANo please list the month,day,year,and location of your conviction(s)
Are you currently sewing a sentence,including any term of probation for operating a motor vehicle while Intoxicated In Indiana or a similar
0 Yes JZrNG crime in another state?
❑Yes No Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(Ifyes,you cannot have a permit until
all liabilities have been paid)
lHave you had an application for an alcoholic beverage permit or employee's permit denied,revoked,or suspended within the last 5 years?lf
❑Yes *0 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.
CqYes ❑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?
No
Yes [3
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
[A
I
permit on demand?
;kes ❑No Do you know that the alcoholic beverage laws are part of the cdrrdnal 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?
r.
7
To receive a Restricted Employee Permit you must attachtbe original Certified Server Training Certificate Issued to you at your training session.Photocopies
will not be accented.
STEP-4.'.'.FEE"AND.PAYMENT.tG14EbuL.
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
Payment by mail may be made by money order,business check,or certified check 00 NOT SEND CASH OR PERSONAL CHECKS.
STEPS '.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 on
this form is true and correct. I understand that it is a k!M 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 day,year)
OWl Background owl 13 No record on file
und Check ❑ No OWI ❑ W
............ -
Eligible lnelig�ible
FOf Office Use I
Conviction Date(s) Eligible Date Initi tr
al&Date
Revealed ❑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 Vasil 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, September 20, 2013
Director, Brooks re 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))
09/20/13 Vasil Renewal Permit $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