STATE OF NEW JERSEY DEPARTMENT OF LAW AND PUBLIC SAFETY DIVISION OF ALCOHOLIC BEVERAGE CONTROL P.O. BOX 087, 140 EAST FRONT STREET TRENTON, NJ 08625-0087 APPLICATION FOR SPECIAL PERMIT AUTHORIZING EMPLOYMENT OF PERSONS UNDER 18 YEARS OF AGE BY AN ALCOHOLIC BEVERAGE LICENSEE [EMP] This application must be accompanied by a fee of $15.00 in the form of check or money order payable to the Division of A.B.C. New applicants must also submit: I. One passport-size photograph (full face)taken within the last 30 days. II. A photocopy of applicant’s Employment Certificate (working papers)issued by his/her District Board of Education. CHECK ONE: NEW APPLICANT ( 1. ) RENEWAL APPLICANT ( ) Full Name of Applicant:_____________________________________ PLEASE PRINT CLEARLY OR TYPE 2. Home Address of Applicant:__________________________________ STREET ADDRESS ________________________________________________________________________ CITY/TOWN STATE ZIP CODE 3. Social Security Number__________-_______-__________ 4. Description of Applicant: Age______________________ Male/Female_________ Date of Birth______/______/______ Hair Color__________ Eye Color________________ Height______________ Weight___________________ NOTE: 5. Are you presently, or have you ever been under the supervision of any parole or probation authority? If yes, you must attach a copy of your court disposition or a letter from your parole officer. YES ( ) NO ( ) American LegalNet, Inc. www.FormsWorkflow.com NOTE: BOTH SIDES OF THIS APPLICATION MUST BE FILLED OUT IN IT=S ENTIRETY BEFORE A PERMIT IS ISSUED. THIS AREA TO BE COMPLETED BY ALCOHOLIC BEVERAGE LICENSEE. (EMPLOYER): 6. Name of Licensee:___________________________________________ PLEASE PRINT CLEARLY OR TYPE 7. Address of Licensed Premises:_______________________________ STREET ADDRESS ____________________________________________________________ CITY/TOWN 8. STATE ZIP CODE 12-Digit License Number________-______-________-________ MUST BE FILLED IN CORRECTLY 9. Contact Name________________________________________________ 10. Contact Telephone Number____________________________________ 11. Description of Applicant’s Job Duties:______________________ ____________________________________________________________ ___________________________________ SIGNATURE OF LICENSEE __________________________ DATED THIS AREA TO BE COMPLETED BY PARENT OR GUARDIAN OF APPLICANT: I, ____________________________________, parent/guardian of _______________________________________, hereby consent to his/her employment by the New Jersey Alcoholic Beverage Licensee named herein. ___________________________________ SIGNATURE OF PARENT/GUARDIAN __________________________ DATED 11/07 American LegalNet, Inc. www.FormsWorkflow.com