APPLICATION FOR EMPLOYEE PERMIT INDIANA ALCOHOL & TOBACCO COMMISSION 302 W. Washington Street, Rm. E114 Indianapolis, Indiana 46204 Employee Permit Section (317) 232-2455 Web page: http://www.IN.gov/atc Hours: 8:00 am to 4:00 pm EST 3 Year Employee Permit - Type 900 2 Year Volunteer Employee Permit - Type 801 2 Year Restricted Permit - Type 300 State Form 43 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 Address (number and street) City State Social Security Number (Mandatory per IC 4-1-8-1 (a) (b)) Sex Height (ft. in.) Weight (lbs.) Zip Date of birth (month, day, year) Age † Male † Female Check one: † Renewal Permit number (if renewal) Check one that applies: † Original application † Employee Permit † 19 -20 year old Restricted Permit † Volunteer Permit 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. STEP 2. BACKGROUND QUESTIONS - READ CAREFULLY PRIOR TO ANSWERING † Yes 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, † No 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 liabilities have been paid) † Yes Have you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the last 5 years?If † No 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. † Yes † 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 † Yes † 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? 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? STEP 3. 19-20 YEAR OLD RESTRICTED PERMIT To receive a Restricted Employee Permit, you must attach the original Certified Server Training Certificate issued to you at your training session. Photocopies will not be accepted. STEP 4. FEE AND 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) You may work on 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 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) OWI Background Check For Office Use Only Conviction Date(s) † No OWI Eligible Date † OWI Eligible † OWI Ineligible Revealed † YES † NO † No record on file Initial & Date American LegalNet, Inc. www.FormsWorkflow.com