Fillable Printable Form 0004
Fillable Printable Form 0004
Form 0004
APPLICATION FOR EMPLOYEE PERMIT
3 Year Employee Permit - Type 900
2 Year Volunteer Employee Permit - Type 801
2 Year Restricted Permit - Type 300
State Form 43 (R22 / 1-15)
Approved by State Board of Accounts, 2015
INDIANA ALCOHOL AND TOBACCO COMMISSION
302 West Washington Street, Room E114
Indianapolis, Indiana 46204
Employee Permit Section: (317) 232-2455
Web page: http://www.IN.gov/atc
Hours: 8:00 am to 4:00 pm EST
* This agency is requesting disclosure of your Social Security Number in accordance with IC 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) (please print) Daytime telephone number
( )
E-mail address
Mailing address (number and street, city, state, and ZIP code)
Social Security Number * Sex
Male Female
Height (feet, inches) Weight (pounds) Date of birth (month, day, year) Age
Driver license number Permit number (if renewal)
Check one that applies:
Employee Permit Volunteer Permit 19-20 year old Restricted Permit
Name and address of permit premises where this permit is to be used (if known). If applying for a Volunteer Permit, list the name and address of the not for profit organization.
STEP 2. BACKGROUND QUESTIONS - READ CAREFULLY PRIOR TO ANSWERING.
Are you aware that you must successfully complete an approved server training course within 120 days of employment?
(Not applicable for 19-20 year old Restricted Permit.)
Yes No
Have you ever been convicted of operating a motor vehicle while intoxicated in Indiana or of a similar charge in any other state
within the last ten (10) years? (If yes, please list the month, day, year, and location of your conviction(s)):
_____________________________________________________________________________________________________
Yes No
Are you currently serving a sentence, including any term of probation for operating a motor vehicle while intoxicated in Indiana or a
similar crime in another state?
Yes No
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.)
Yes No
Have you had an application for an alcoholic beverage permit or employee's permit denied, fined, revoked, or suspended within the
last five (5) years? If yes, explain: ____________________________________________________________________________
Yes No
Have you ever had a driver’s license / state identification in any state other than Indiana in the last ten (10) yea rs?
If so, you must attach a copy of your driving record from that state.
Yes No
Do you know that an excise officer may enter, inspect, and search the permit premises in which you work without a warrant and you
must produce your permit on demand?
Yes No
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?
Yes No
Do you understand that this employee permit is yours and that your employer is only allowed to copy the permit?
Yes No
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?
Yes No
STEP 3. 19-20 YEAR OLD RESTRICTED PERMIT
To receive a Restricted Employee Permit, you must attach the original Certified Server Training Certificate issued to you at your training session.
Photocopies will not be accepted.
STEP 4. FEE AND PAYMENT SCHEDULE
Type 900 - 3 Year Employee Permit (Fee $45.00 – THIS FEE IS NON-REFUNDABLE.)
Type 801 - Volunteer Employee Permit (voluntary services only for nonprof it organizations) (Fee $15. 00 – THIS FEE IS NON-REFUNDABLE.)
Type 300 - 2 Year Restricted Permit (Fee $30. 00 – T H IS FEE IS NON-R E F U NDA BL E.)
You may work on your receipt pending issuance of your permit.
Payment by mail may be made by money order, business check, or certified check made payable to the Indiana Alcohol and Tobacco Commission and mailed to
the above address. DO NOT SEND CASH OR PERSONAL CHECKS.
STEP 5. SIGNATURE AND AFFIRMATION
I certify that this application was completed by myself. I affirm under penalties of perjury that I am at least nineteen (19) years of age and that all
information provided on this form is true and correct. I understand that it is a Level 6 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
Operating while intoxicated (OWI) background check
No OWI OWI Eligible OWI Ineligible No record on file
Date(s) of conviction (month, day, year) Date eligible (month, day, year) Revealed
Yes No
Initial Date (month, day, year)
Reset Form
