302 West Washington Street IGCS Room E114 Indianapolis, IN 46204 STATE OF INDIANA ALCOHOL AND TOBACCO COMMISSION Telephone 317 / 232-2430 Fax 317 / 233-6114 www.IN.gov/atc RE: Supplemental Catering Permit Fee Dear Permittee: Public Law 250 changes the supplemental catering permit fee to $150 per year. This change became effective July 1, 2003. If you wish to hold a supplemental catering permit, you must submit a written request to the Alcohol and Tobacco Commission (ATC) accompanied by the $150 fee. For your convenience, you may simply complete the lower portion of this letter and submit it with your payment to the ATC. Upon receipt, the $150 fee will be prorated based on the current expiration date of your three-way permit. Please remember that the ATC will only accept a business check, money order or certified check through the mail. Personal checks will not be accepted and please Do Not Send Cash! If you have any questions, please call 317-232-2430 or call your processor directly. Thank you. Sincerely, Dave Heath Chairman Reset Form REQUEST FOR A SUPPLEMENT CATERING PERMIT State Form 54365 (7-10) Approved by State Board of Accounts, 2011 Name: __________________________________ Permit Number: __________________________ Address: ________________________________________________________________________________ Doing Business As (DBA): _________________________________________________________________ Please submit this information with a fee of $150 to: Alcohol and Tobacco Commission IGCS Room E114 302 W. Washington Street Indianapolis IN 46204 AN EQUAL OPPORTUNITY EMPLOYER American LegalNet, Inc. www.FormsWorkFlow.com