Application For Temporary Employee Permit {54632}

APPLICATION FOR TEMPORARY EMPLOYEE PERMIT State Form 54632 (12-13) Approved by State Board of Accounts, 2013 INSTRUCTIONS: 1. Type or print legibly. 2. Complete all sections. INDIANA ALCOHOL AND TOBACCO COMMISSION TEMPORARY PERMIT SECTION 302 W. Washington Street, Rm. E114 Indianapolis, Indiana 46204 Telephone number: (317) 234-4315 Website: 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 * Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. STEP 1. GENERAL INFORMATION Name of applicant (first, middle initial, last) Address (number and street, city, state, and ZIP code) Social Security number * Temporary permit number Location where Temporary Permit is to be used: Sex Male Height (ft. in.) Female Date(s) of Temporary Permit (month, day, year) Weight (lbs.) Date of birth (month, day, year) Age Daytime telephone number ( ) E-mail address STEP 2. BACKGROUND QUESTIONS - READ CAREFULLY PRIOR TO ANSWERING Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No 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 month, day, year, and location of your conviction(s) ___________________________________________ Are you currently serving a sentence, including any term of probation for operating while intoxicated in Indiana or a similar crime in another state? 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). Have you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the last five (5) years? If yes, explain : ______________________________________________________________________ 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. Do you know that it is a Class B Misdemeanor, punishable by up to six (6) months in jail and a $1,000 fine, for knowingly serving an intoxicated person? 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? 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? 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 twenty-one (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) FOR OFFICE USE ONLY OWI Background Check Conviction Date(s) (month, day, year) No OWI Eligible Date (month, day, year) OWI Eligible Revealed OWI Ineligible Yes No No record on file Initial & Date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com