APPLICATION FOR EMPLOYEE PERMIT 3 Year Employee Permit - Type 900 2 Year Volunteer Employee Permit - Type 801 2 Year Restricted Permit - Type 300 State Form 43 (R22 / 1-15) Approved by State Board of Accounts, 2015 INDIANA ALCOHOL AND TOBACCO COMMISSION 302 West Washington Street, Room 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 * This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it. STEP 1. GENERAL INFORMATION Name of applicant (first, middle initial, last) (please print) Mailing address (number and street, city, state, and ZIP code) Social Security Number * Driver license number Sex Height (feet, inches) Weight (pounds) Date of birth (month, day, year) Age Daytime telephone number E-mail address ( ) Male Female Check one that applies: Permit number (if renewal) Employee Permit Volunteer Permit 19-20 year old Restricted 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. Are you aware that you must successfully complete an approved server training course within 120 days of employment? (Not applicable for 19-20 year old Restricted Permit.) Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge in any other state within the last ten (10) years? (If yes, 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 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 all liabilities have been paid.) Have you had an application for an alcoholic beverage permit or employee's permit denied, fined, revoked, or suspended within the last five (5) years? If yes, explain: ____________________________________________________________________________ Have you ever had a driver's license / state identification in any state other than Indiana in the last ten (10) years? If so, you must attach a copy of your driving record from that state. 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? 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? Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit? Do you know that it is a Class B Misdemeanor, punishable by up to six (6) months in jail and a $1,000 fine, for knowingly serving an intoxicated person? 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 ­ THIS FEE IS NON-REFUNDABLE.) Type 801 - Volunteer Employee Permit (voluntary services only for nonprofit organizations) (Fee $15. 00 ­ THIS FEE IS NON-REFUNDABLE.) Type 300 - 2 Year Restricted Permit (Fee $30. 00 ­ THIS FEE IS NON-REFUNDABLE.) You may work on your receipt pending issuance of your permit. Payment by mail may be made by money order, business check, or certified check made payable to the Indiana Alcohol and Tobacco Commission and mailed to the above address. DO NOT SEND CASH OR PERSONAL CHECKS. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No 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 nineteen (19) years of age and that all information provided on this form is true and correct. I understand that it is a Level 6 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) FOR OFFICE USE ONLY Operating while intoxicated (OWI) background check No OWI Date(s) of conviction (month, day, year) OWI Eligible OWI Ineligible Revealed No record on file Initial Date (month, day, year) Date eligible (month, day, year) Yes No American LegalNet, Inc. www.FormsWorkFlow.com