Application For Alcoholic Beverage Permit Schedule MQ {40767}

APPLICATION FOR ALCOHOLIC BEVERAGE PERMIT SCHEDULE - MQ Managerss Questionnaire State Form 40767 (R5 / 12-02) ATC USE ONLY Received Entered Processors initials INSTRUCTIONS: Every application must be filed in duplicate. This form must be completed by the manager. PERMIT PREMISE NUMBER (Please Print) 1. GENERAL INFORMATION Name of manager (last, first, middle initial) ATC employee permit number Home address (number and street) City, state, ZIP code Expiration date Age Sex * Your Social Security number is being requested by this state agency in order to pursue its statutory responsibilities. Disclosure is mandatory and this application cannot be processed without it. Social Security number * Date of birth Height Weight Male Female 1. GENERAL QUESTIONS Are you a citizen of the United States? Are you 21 years old? Is it true you are not an officer or employee of a person engaged in the alcoholic beverage traffic, which person is a non-resident of this state, or is engaged in carrying on any phase of manufacture of, traffic in, or transportation of alcoholic beverages without a permit when one is required? Are you a State law enforcement officer, or a non-elected officer of a municipal corporation or government subdivision charged with any duty or function in the enforcement of Alcoholic Beverage Laws? Has your alcoholic beverage permit been revoked within one year prior to the date of this application for a permit? Have you made an application for a permit of any type which has been denied less than one year prior to this application for a permit? (Unless the application was denied by a reason of a procedural or technical defect.) Are you now and have you been for the five years last past a continuous and bona fide resident of the State of Indiana? If no, does the permit premise you are managing have a minimum annual gross food sales of at least $100,000? Do you hold any other permit of any kind for the sale of alcoholic beverages in Indiana, or do you have any interest in any such permit, directly or indirectly, through ownership of stock or otherwise? If yes, explain below: Yes Yes Yes No No No Yes Yes Yes Yes Yes No No No No No Have you been convicted of a felony? If yes, attach places and dates of arrest, court of record, and conviction and attach relevant court record. Have you ever been convicted of a violation of the Indiana Alcoholic Beverage Laws, rules, regulations, or orders of the Commission? If yes, explain on a separate attachment: 3. SIGNATURES Signatures of manager or agent referred to in this schedule Signature of owner verifies that the manager listed above meets the above listed qualifications Yes Yes No No American LegalNet, Inc. www.FormsWorkFlow.com