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Temporary Employee Permit Application Form. This is a Indiana form and can be use in Alcohol And Tobacco Commission Statewide.
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Tags: Temporary Employee Permit Application, 43, Indiana Statewide, Alcohol And Tobacco Commission
TEMPORARY EMPLOYEE PERMIT APPLICATION
INDIANA ALCOHOL & TOBACCO COMMISSION
State Form 43 (R4/4-06)
Approved by State Board of Accounts, 2006
302 W. Washington Street, Rm. E114
Indianapolis, Indiana 46204
Temporary Permit Section (317) 234-4315
Web page: http://www.IN.gov/atc
● This permit may be issued for use at the location covered by and
during the time period of Temporary permit only.
STEP 1. GENERAL INFORMATION
Name of applicant (first, middle initial, last) (please print)
Daytime telephone number
E-mail address
Address (number and street)
City
State
Social Security Number (Mandatory per IC 4-1-8-1 (a) (b))
Sex
Height (ft. in.)
Male
Temporary Permit Number:
Weight (lbs.)
Zip
Date of birth (month, day, year)
Age
Female
Date(s) of Temporary Permit:
Location where Temporary Permit is to be used:
STEP 2. BACKGROUND QUESTIONS - READ CAREFULLY PRIOR TO ANSWERING
Yes
Have you ever been convicted of operating while intoxicated in Indiana or of a similar charge in any other state? (If yes, please list the
No month, day, year, and location of your conviction(s) ______________________________________________
Yes
No
Are you currently serving a sentence, including any term of probation for operating while intoxicated in Indiana or a similar crime in
another state?
Yes
No
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)
Yes
No If yes, explain ______________________________________________________________________
Yes
No Have you ever had a drivers license in any other state? If so, you must attach a copy of your driving record from that state.
Yes
No Do you know that it is a Class B Misdemeanor, punishable by up to 6 months in jail and a $1,000 fine, for knowingly serving an intoxicated person?
Yes
No
Do you know that an excise officer may enter, inspect, and search a permit premises in which you work without a warrant and you must produce
proof of your temporary employee permit on demand?
Yes
No
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?
Have you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the last 5 years?
STEP 3. FEE AND PAYMENT SCHEDULE
Temporary Employee Permit
(Fee $5.00)
You may work on your receipt at the Temporary event noted on this application.
Payment by mail may be made by money order, business check, cashier's check, or certified check. Cash accepted only if hand delivered to ATC office.
STEP 4. SIGNATURE AND AFFIRMATION
I certify that this application was completed by myself. I affirm under penalties of perjury that I am at least 21 years of age and 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)
OWI Background Check
For Office Use Only Conviction Date(s)
No OWI
Eligible Date
OWI
Eligible
Revealed
OWI
Ineligible
YES
NO
No record on file
Initial & Date
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