APPLICATION FOR ALCOHOLIC BEVERAGE PERMIT SCHEDULE - MQ ATC USE ONLY Received Manager's Questionnaire State From 40767 (R 6 / 10/02) Entered INSTRUCTIONS: Every application must be filled in duplicate Processors initials This form to be completed by the manager PERMIT PREMISE NUMBER (Please print) 1. GENERAL INFORMATION Name of manager (last, first, middle initial) ATC Employee permit number Social Security Number Expiration date Age Sex Date of birth Male Height Weight Female Home address (number and street) City, state, zip 2. GENERAL QUESTIONS Are you a citizen of the United States? Yes No Are you at least twenty-one (21) years old? Yes No Is it true that you are not an officer or employee of a person engaged in the alcoholic beverage traffic, which person is a non-resident of this state, or is engaged in carrying on any phase of manufacture of, traffic in, or transportation of alcoholic beverages without a permit when one is required? Yes No Are you a State law enforcement officer, or a non-elected officer of a municipal corporation or government subdivision charged with any duty or function in the enforcement of Alcoholic Beverage Laws? Yes No Has your alcoholic beverage permit been revoked within one year prior to the date of this application for a permit? Yes No Have you made an application for a permit of any type which has been denied less than one year prior to this application for a permit? (Unless the application was denied by a reason of a procedural or technical defect.) Yes No Are you now, and have you been for the last five years a continuous and bona fide resident of the State of Indiana? If no, does permit premise you are managing have a minimum annual gross food sales of at least $100,000? Yes No Do you hold any other permit of any kind for the sale of alcoholic beverages in Indiana, or do you have any interest in any such permit, directly or indirectly, through ownership of stock or otherwise? If yes, explain below: Yes No Have you been convicted of a felony? If yes, attach places and dates of arrest, court of record, and conviction and attach relevant court record. Yes No Have you been convicted of a violation of the Indiana Alcoholic Beverage Laws, rules, regulations, or orders of the Commission? If yes, explain on a separate attachment. Yes No the 3. SIGNATURES Signatures of manager or agent(s) referred to in this schedule Signature of owner verifies that the manager listed above meets the above listed qualifications American LegalNet, Inc. www.FormsWorkflow.com