APPLICATION FOR SALESMAN PERMIT CHECK APPROPRIATE BOX State Form 33 (R5 / 6-11) A: TYPE 701 - Brewer, Beer, Wine and Liquor Wholesalers Approved by the State Board of Accounts, 1990 B: TYPE 702 - Distillery, Rectifier, Winery, Importer C: TYPE 703 - Agent/Representative Fee -- $20.00 for two years. We accept only cashier's check, certified check, or money order. STEP 1. GENERAL INFORMATION Applicant's Name Age Sex Date of Birth Home Telephone Number Business Telephone Number Social Security Number Street Address City State Driver License Number: Permit Number (if renewal) Name of employer: Permit number (if renewal) Expiration Date Physical Address (number and street) City State M Height Weight F ZIP code E-mail address STEP 2. EMPLOYER INFORMATION ZIP code STEP 3. BACKGROUND QUESTIONS - READ CAREFULLY PRIOR TO ANSWERING  Yes  No Are you aware that a salesman is any person who procures or seek to procure and order, bargain, contract, or agreement for the sale, for the delivery, or for the transportation of alcoholic beverages, or who is engaged in promoting the sale of alcoholic beverages, or in promoting the business of any person engaged in the manufacturing, selling, delivery or transportation of alcoholic beverages for sale or delivery, whether whether the seller resides within Indiana and sells to buyers either within or without Indiana?  Yes  No Are you aware that no salesman's or agent's permit shall be issued to any person unless he is of good moral  Yes  No Are A you aware if you violate any l i l t law concerning alcoholic beverages or any rule of the commission made i l h li b l f th i i d  Yes  No Are you aware you must be prepared to exhibit their permits at any time while engaged in soliciting, taking  Yes  No character? pursuant to law the commission can revoke your permit? orders for, or promoting the sale of, alcoholic beverages upon demand of a duly authorized representative of the commission, or upon the request of any permittee? Are you aware if a licensed salesman changes employment to another permittee, he shall notify the commission within fifteen (15) days? Failure to notify the commission within the specified time shall make the salesman ineligible for the issuance of any kind of alcoholic beverage permit for definite period to be determined by the commission?  Yes  No Are you aware if a licensed salesman changes his address, he shall notify the commission within fifteen (15) days? Failure to notify the commission within the specified time shall make the salesman ineligible for the issuance of any kind of alcoholic beverage permit for definite period to be determined by the commission?  Yes  No Are you aware that you must hold a Salesman's permit for every company you work for or represent? STEP 4. SIGNATURE AND AFFIRMATION I certify that this application was completed by myself. I affirm under penalties of perjury that 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) American LegalNet, Inc. www.FormsWorkFlow.com