HomeMy WebLinkAbout224934 10/08/2013 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMM CHECK AMOUNT: $45.00
2 CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114
INDIANAPOLIS IN 46204 CHECK NUMBER: 224934
CHECK DATE: 10/8/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 GENGENBACH 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
Indianapolis,Indiana 46204
2 Year Volunteer Employee Permit-Type 801 Employee Permit Section(317)232-2455
reps 2 Year Restricted Permit-Type 300 Web page:http:/Awvw.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'-1 INFORMATION
N
Name of applicant(first,middle initial,last)(please print) Daytime telephone number E-mail address
'73 f--
Address
-(number and street) Cify state Zip J 3
166 )/ I'J 'e—�I-J"act 6 v
Social Security Number(Mandatory per/C 4-1-8-1(a)(b)) Sex Height(it-in.) Weight(Ibs.) Date of birth(month,da)i,year) Age
Check one: Permit number(if renewal) Check one that applies: Cl- Employee Permit E3 19-20 year old Restricted Perrrgt
13 Renewal 12110"dginal application ❑ Volunteer Permit
Name and address of permit premises where this permit is to be us ed(it known),
B applying for a Volunteer Permit,list the name and address of the not for profit organization.
64 IiW CAREFULLY PRIOR-TD AhSWERING
'
0/ ever een convicted of operating a motor vehicle while intoxicated In Indiana or of a similar charge in any other state?(Ifyes,
er
Oyes
Have you No please list the month,day,year,and location of your conviction(s)
Are you currently serving a sentence,including any term of probation for operating a motor vehicle while intoxicated In Indiana or a similar
0 Yes GiNci
crime in another state?
Do you have any outstanding and unpaid tax liabilities owing to the Indiana Department of Revenue?(If yes,you cannot have a permit until
0 Ye�s Co all liabilities have been paid)
0 Yes C*/. 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,explain
❑Yes GNO Have you had a drivers license In any other state In the last 10 years? 11'so,you must attach a copy ol'your driving record from that state.
te.
Yes 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?
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
es permit on demand?
Yes 40o 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 es ONo 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 oriciinal Certified Server Training Certificate issued to you at your training session.Photocopies
M t
accepted
ill receive
d.
PAYMENT SCHEDULE.
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)
Si
You may work an your receipt for only 30 days
Payment by mail maybe made by money order,business check,or certified check DO NOT SEND CASH OR PERSONAL CHECKS.
S TEO. 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 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,day,year)
0 0 owl
Owl Background Check ❑ No Owl ible
Eligowl Ineligible ❑ No record on file
For,Office'Use'Plfily'l Initial&Date
Conviction Date(s) Eligible Date
Revealed ❑YES ONO
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 Gengenbach 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
Tuesday, October 01, 2013
Director, B shire 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))
09/28/13 Gengenbach 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