Supplemental Catering Permit {54365}

STATE OF INDIANA 302 West Washington Street IGCS Room E114 Indianapolis, IN 46204 Telephone 317 / 232-2430 Fax 317 / 233-6114 www.IN.gov/atc ALCOHOL AND TOBACCO COMMISSION RE: Supplemental Catering Permit Fee Dear Permittee: 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. 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, David Cook ATC Chairman REQUEST FOR A SUPPLEMENTAL CATERING PERMIT State Form 54365 (R / 1-15) Approved by State Board of Accounts, 2015 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