APPLICATION FOR RENEWAL OF ALCOHOLIC BEVERAGE PERMIT State Form 47 (R14/ 7-10) Approved by State Board of Accounts, 2011 FOR OFFICE USE ONLY Examined by / date INSTRUCTIONS: 1. Type or print legibly. 2. Submit in duplicate. Include payment 3. Application must be received by our office 75 days (2 1/2 months) before permit expires. 4. Do not complete shaded areas. Hearing date Issue date New expiration date STEP 1. GENERAL INFORMATION Name of applicant as printed on existing permit Permit Number Name of Business (d/b/a) State Tax I.D. number Business Address (number and street, city, state, and ZIP code ) Business Telephone Number (include area code) ( Permit Type Release date Permit expiration date Base fee - ) Home Telephone Number (include area code) ( Mailing address (number and street, city, state, and ZIP code ) Name of Processor Date of Renewal ) Active Status - Non-operational / Escrow (Attach escrow letter ) Excise District Catering Local Board 1) Have there been any changes in the existing operation, floor plans, or seating accommodations since you last applied for this permit? (If Yes, attach affidavit of changes and copies of amended floor plan on 8.5" x 11" paper if applicable) Yes No 2) Do you consent for the duration of the permit to inspection and search by an enforcement officer, without a warrant or other process, of your licensed premise and vehicles to determine compliance with the provisions of I.C. 7.1? Yes No Yes No 4) Since your last renewal have you been convicted of any misdemeanor or felony? (If Yes, please attach letter with dates, court, conviction, and sentence of conviction) Yes No 5) Do you have the right to possess (rent, mortgage, or own) the permit premise for the term of the permit? Yes No 6) Have all your sales taxes and property tax obligations for the past year and those due at this time been paid in full? Yes No 7) Do you sell tobacco products? Yes No 3) Does the permittee have an interest in any distiller, vintner, farm winery, rectifier, brewer, primary source of supply, or wholesaler permit? STEP 2. BUSINESS OWNERSHIP Check one: Corporation Limited Liability Company Limited Liability Partnership Partnership Limited Partnership Club Sole ownership CORPORATIONS ONLY Note: If the ownership has changed (by death, transfer or sale of stock or interest, etc.) since you last applied for renewal, the processor should be notified at once before completing this section. Provide the information for the individuals associated with your permit as follows: Total shares authorized CLUB - Highest ranking officer and the financial secretary or treasurer CORPORATION - President, secretary, and all stockholders (list total shares authorized / issued and individual shares held and percent of shares issued ) LIMITED LIABILITY COMPANY - All members and percent of interest held LIMITED PARTNERSHIP / PARTNERSHIP / LIMITED LIABILITY PARTNERSHIP - All partners and percent of interest held SOLE OWNERSHIP - Owner TITLE NAME AND HOME ADDRESS *SOC. SEC. NO. & DOB Total shares issued SHARES OR INTEREST HELD IF APPLICABLE SSN DOB SSN DOB SSN DOB SSN DOB *Social Security Numbers are required by federal child support law Enclose an additional sheet if necessary American LegalNet, Inc. www.FormsWorkFlow.com % STEP 3. ANNUAL FOOD SALES Required for the following permits: Type 209 (except golf courses); All retail permits with less than 60% ownership by Indiana residents; Retail permits with limited bar / family room separation; All grocery store permits. Date of beginning report (month, day, year) Date of ending report (month, day, year) Gross sales (exclude all gasoline and auto oil products) Gross Alcoholic beverage sales Gross food and beverage sales STEP 4. OPERATION INFORMATION Is there a contract of any kind to sell the permit/business at this time? Yes No Have you conducted server training since your last renewal? Yes No Yes No Yes No As owner do you manage the premises? Yes No If No, do you monitor the premises? Are you a grocery store or pharmacy? Yes If business is a grocery store, are 25% or less of the gross sales in alcoholic beverages? No (If no, then you MUST complete the rest of this section) The Alcohol and Tobacco Commission requires the following of all managers: They must have been an Indiana resident for five (5) years or work in a restaurant with a minimum of $100,000 annual food sales; They must be a United States citizen or resident alien; They must be of sound mind, 21 years of age and of good moral character; They cannot be a law enforcement officer; and They cannot have a conviction within the last ten (10) years of an A, B or C felony, in any state, or a federal crime with a sentence of at least one (1) year. Do you understand the requirements and attest that the managers listed below meet these qualifications?_______________ ( initial ) The Alcohol and Tobacco Commission requires managers as follows: At least one for each permit premise; The manager must have an employee permit unless he or she is a sole proprietor, partner or stockholder The manager is someone who has day-to-day authority over: 1. employees that hold employee permits (i.e. bartenders, servers); 2. the receipt, inventory, stocking, and marketing of alcoholic beverages; 3. the premises, in the event of an emergency. LIST THE MANAGERS FOR THIS PREMISE (ENCLOSE AN ADDITIONAL SHEET IF NECESSARY ) NAME EMPLOYEE PERMIT # or OWNERSHIP TYPE EMERGENCY TELEPHONE NUMBER STEP 5. AFFIDAVIT OF APPLICANT I certify that there have been no changes regarding my previous application except those noted herein. I certify that this application was completed by myself or by the preparer identified herein. I certify that my premise ownership is true and that I will provide a copy of any applicable lease or purchase by contract upon request of the Commission. I certify that I have met any applicable food and beverage sales requirements. I certify that all information provided herein and on any attached schedules or documents are true and correct. I UNDERSTAND THAT IT IS A FELONY UNDER LAW TO MISREPRESENT OR FALSIFY ANY PORTION OF THIS APPLICATION OR ATTACHED DOCUMENTS. I hereby consent for the duration of the permit term to inspection and search by an enforcement officer, without a warrant or other process, of my licensed premise and vehicles to determine compliance with the provisions of I.C. 7.1 Printed name of applicant Signature of applicant Date (month, day, year ) STEP 6. AFFIDAVIT OF PREPARER (IF APPLICABLE) I certify that I have examined this application and the accompanying forms, schedules, and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Signature of preparer Telephone number ( Date (month, day, year ) ) STEP 7. FEE Please remit business, certified checks, or money order - application will not be processed without payment One-way (beer only) = $500 Two-way (beer & wine only) = $750 Three-way (beer, wine, & liquor) = $1,000 (Except Fraternal Clubs) = $250 Submit in duplicate and MAIL TO: INDIANA ALCOHOL & TOBACCO COMMISSION 302 West Washington Street, Room E114 Indianapolis, Indiana 46204 American LegalNet, Inc. www.FormsWorkFlow.com