Application For Salesman Permit {33}

APPLICATION FOR SALESMAN PERMIT State Form 33 (R7 / 4-16) Approved by the State Board of Accounts, 2016 CHECK APPROPRIATE BOX. A: TYPE 701 - Brewer, Beer, Wine and Liquor Wholesalers B: TYPE 702 - Distillery, Rectifier, Winery, Importer C: TYPE 703 - Agent / Representative Fee -- $20.00 for two (2) years. We accept only cashier's check, certified check, or money order. *Your social security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. FOR OFFICE USE ONLY Application fee Permit number (if new application) Date fee receipted (month, day, year) Receipt Number Date issued (month, day, year) STEP 1. GENERAL INFORMATION Applicant's Name Home Telephone Number Street Address (number and street) Driver License Number Age Sex Date of Birth (month, day, year) Height Weight Male Female Social Security Number * State E-mail address ZIP code Business Telephone Number City Permit Number (if renewal) STEP 2. EMPLOYER INFORMATION Name of employer Physical Address (number and street) Permit number City Expiration Date (month, day, year) State ZIP code Yes No Yes Yes Yes No No No Yes No STEP 3. BACKGROUND QUESTIONS - READ CAREFULLY PRIOR TO ANSWERING 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 i th manufacturing, selling, d li fti lli delivery or t transportation of alcoholic b t ti f l h li beverages f sale or d li for l delivery, whether h th the seller resides within Indiana and sells to buyers either within or without Indiana? (IC 7.1-1-3-41) Are you aware that no salesman's or agent's permit shall be issued to any person unless he is of good moral character? (905 IAC 1-8-1(b)) Are you aware if you violate any law concerning alcoholic beverages or any rule of the commission made pursuant to law the commission can revoke your permit? (905 IAC 1-8-1(d)) Are you aware you must be prepared to exhibit your permits at any time while engaged in soliciting, taking 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? (905 IAC 1-8-3)) Are you aware if a licensed salesman changes employment to another permittee, he or she 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. (906 IAC 1-8-6) Are you aware if a licensed salesman changes his or her address, he or she 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. (905 IAC 1-8-7) Are you aware that you must hold a Salesman's permit for every company you work for or represent? (905 IAC 1-8-5 and IC 7.1-3-18-8(b)) STEP 4. SIGNATURE AND AFFIRMATION Yes No Yes No I certify that this application was completed by myself. I affirm under penalties of perjury 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) MAIL TO: Indiana Alcohol and Tobacco Commission 302 West Washington Street, Room E114 Indianapolis, Indiana 46204 American LegalNet, Inc. www.FormsWorkFlow.com