APPLICATION FOR PERMIT CHECK APPROPRIATE BOX State Form 33 (R4 / 6-90) A: TYPE 701 - Brewer, Beer, Wine and Liquor Wholesalers Approved by the State Board of Accounts, 1990 B: TYPE 702 - Distillery, Rectifier, Winery, Importer Fee -- $20.00 for two years. We accept only cashier's check, certified check, or money order. Applicant's Name Age Sex Date of Birth Home Telephone Number Business Telephone Number Social Security Number Street Address City State Representing Agent Address M Height Weight F ZIP code ALL APPLICANTS 25 YEARS OLD AND UNDER MUST ATTACH A COPY OF THEIR BIRTH CERTIFICATE Do you hold other permits of this type? Yes Do you have interest in any other alcoholic beverage permits (Retailer, Dealer, ect. ) No Yes If yes, state for whom: No If yes, please explain and give permit number: Name other Employers (If any ) Have you ever been convicted of a felony or misdemeanor, or imprisoned? Yes No If yes, please explain. APPLICANT'S STATEMENT The foregoing statements are true and I will comply with the rules, regulations and orders of the commission. STATE OF________________________________ COUNTY OF______________________________ Applicant's Signature SS: Subscribed and sworn to before me this ________________________day of _______________________________, 20_____________. Notary's Signature Notary's Name (Typed or Printed ) Commission's Expiration Date County of Residence EMPLOYER'S STATEMENT The aforementioned employer, who is the holder of a _____________________________________ permit, No. _____________________________, and whose address is _________________________________________________________________________________________hereby certifies that ___________________________________ is __________ years old, has resided in the State of Indiana _________ months, has been in the employ of our Company, _______________________________, as ___________________________ and is a person of good moral character. I further certify that I have made a personal investigation of the fitness and character of the applicant, as named above, and recommended a salesnam's permit be granted. Name of Employer Official Position Name of Company By: STATE OF________________________________ COUNTY OF______________________________ SS: Subscribed and sworn to before me this ________________________day of _______________________________, 20_____________. Notary's Signature Notary's Name Commissioner's Expiration Date County of Residence American LegalNet, Inc. www.FormsWorkflow.com