Application For Alcoholic Beverage Permit Schedule MQ Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For Alcoholic Beverage Permit Schedule MQ Form. This is a Indiana form and can be use in Alcohol And Tobacco Commission Statewide.
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Tags: Application For Alcoholic Beverage Permit Schedule MQ, 40767, Indiana Statewide, Alcohol And Tobacco Commission
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Has your alcoholic beverage permit been revoked within one year prior to the date of this application for a permit?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
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