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 American LegalNet, Inc. www.FormsWorkflow.com