APPLICATION FOR RENEWAL OF ALCOHOLIC BEVERAGE

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APPLICATION FOR RENEWAL O

ALCOHOLIC BEVERAGE PERMI

State Form 47 (R14/ 7-10)

Approved by State Board of Accounts, 201

Examined by / date

INSTRUCTIONS: 1. Type or print legibly.

Hearing date

2. Submit in duplicate. Include payment

3. Application must be received by our office 75 days (2 1/2 months) before permit expires.

Issue date

4. Do not complete shaded areas.

New expiration date

Name of applicant as printed on existing permit Permit Number Permit Type Release date

Name of Business (d/b/a) State Tax I.D. number Permit expiration date

Business Address (number and street, city, state, and ZIP code )

Business Telephone Number (include area code) Base fee

( ) -

Home Telephone Number (include area code)

( ) -

Mailing address (number and street, city, state, and ZIP code ) Status

 Active  Non-operational / Escrow

Catering

(Attach escrow letter )

Name of Processor Date of Renewal Excise District Local Board

1) Have there been any changes in the existing operation, floor plans, or seating accommodations since you last applied for

this permit? (If Yes, attach affidavit of changes and copies of amended floor plan on 8.5" x 11" paper if applicable)

2) Do you consent for the duration of the permit to inspection and search by an enforcement officer, without a warrant or other

process, of your licensed premise and vehicles to determine compliance with the provisions of I.C. 7.1?

3) Does the permittee have an interest in any distiller, vintner, farm winery, rectifier, brewer, primary source of supply, or

wholesaler permit?

4) Since your last renewal have you been convicted of any misdemeanor or felony? (If Yes, please attach letter with dates,

court, conviction, and sentence of conviction)

Check one:

 Corporation

 Limited Liability Company  Partnership  Limited Partnership  Club



Limited Liability Partnership  Sole ownership

Note: If the ownership has changed (by death, transfer or sale of stock or interest, etc.) since you last applied for renewal,

the processor should be notified at once before completing this section.

Provide the information for the individuals associated with your permit as follows:

CLUB - Highest ranking officer and the financial secretary or treasurer

CORPORATION - President, secretary, and all stockholders (list total shares authorized / issued and individual shares held

and percent of shares issued )

LIMITED LIABILITY COMPANY - All members and percent of interest held

LIMITED PARTNERSHIP / PARTNERSHIP / LIMITED LIABILITY PARTNERSHIP - All partners and percent of interest held

SOLE OWNERSHIP - Owner

SSN

DOB

SSN

DOB

SSN

DOB

SSN

DOB

*Social Security Numbers are required by federal child support law

NAME AND HOME ADDRESSTITLE *SOC. SEC. NO. & DOB

SHARES OR

INTEREST HELD

IF APPLICABLE

 Yes  No

5) Do you have the right to possess (rent, mortgage, or own) the permit premise for the term of the permit?

 No

 Yes

 No Yes

Enclose an additional sheet if necessary

 No

Total shares authorized

7) Do you sell tobacco products?

 Yes

6) Have all your sales taxes and property tax obligations for the past year and those due at this time been paid in full?

 No

STEP 2. BUSINESS OWNERSHIP

FOR OFFICE USE ONLY

STEP 1. GENERAL INFORMATION

CORPORATIONS ONLY

 Yes

Total shares issued

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Required for the following permits: Type 209 (except golf courses); All retail permits with less than 60% ownership by Indiana residents;

Retail permits with limited bar / family room separation; All grocery store permits.

Date of beginning report (month, day, year) Date of ending report (month, day, year)

Gross sales (exclude all gasoline and auto oil products) Gross Alcoholic beverage sales Gross food and beverage sales

Are you a grocery store or pharmacy?



Yes If business is a grocery store, are 25% or less of the gross sales in alcoholic beverages? Yes No



No (If no, then you MUST complete the rest of this section)

The Alcohol and Tobacco Commission requires the following of all managers:

They must have been an Indiana resident for five (5) years or work in a restaurant with a minimum of $100,000 annual food sales;

They must be a United States citizen or resident alien;

They must be of sound mind, 21 years of age and of good moral character;

They cannot be a law enforcement officer; and

They cannot have a conviction within the last ten (10) years of an A, B or C felony, in any state, or a federal crime with a sentence

of at least one (1) year.

Do you understand the requirements and attest that the managers listed below meet these qualifications?_______________ ( initial )

The Alcohol and Tobacco Commission requires managers as follows:

At least one for each permit premise;

The manager must have an employee permit unless he or she is a sole proprietor, partner or stockholder

The manager is someone who has day-to-day authority over:

1. employees that hold employee permits (i.e. bartenders, servers);

2. the receipt, inventory, stocking, and marketing of alcoholic beverages;

3. the premises, in the event of an emergency.

I certify that there have been no changes regarding my previous application except those noted herein. I certify that this application was completed by myself

or by the preparer identified herein. I certify that my premise ownership is true and that I will provide a copy of any applicable lease or purchase

by contract upon request of the Commission. I certify that I have met any applicable food and beverage sales requirements. I certify that all information

provided herein and on any attached schedules or documents are true and correct. I UNDERSTAND THAT IT IS A FELONY UNDER LAW TO MISREPRESENT

OR FALSIFY ANY PORTION OF THIS APPLICATION OR ATTACHED DOCUMENTS.

Printed name of applicant Signature of applicant Date (month, day, year )

I certify that I have examined this application and the accompanying forms, schedules, and statements, and to the best of my knowledge and belief, they

are true, correct, and complete.

Signature of preparer Telephone number Date (month, day, year )

( )

Please remit business, certified checks, or money order - application will not be processed without payment

One-way (beer only) =

$500

Two-way (beer & wine only) =

$750

Three-way (beer, wine, & liquor) =

$1,000

302 West Washington Street, Room E114

(Except Fraternal Clubs) = $250 Indianapolis, Indiana 46204

 Yes  No

Is there a contract of any kind to sell the permit/business at this time?

STEP 3. ANNUAL FOOD SALES

 Yes

I hereby consent for the duration of the permit term to inspection and search by an enforcement officer, without a warrant or other process, of my licensed premise and

vehicles to determine compliance with the provisions of I.C. 7.1

STEP 7. FEE

 No

INDIANA ALCOHOL & TOBACCO COMMISSION

 No

MAIL TO:

STEP 5. AFFIDAVIT OF APPLICANT

STEP 6. AFFIDAVIT OF PREPARER (IF APPLICABLE)

As owner do you manage the premises?

NAME EMPLOYEE PERMIT # or OWNERSHIP TYPE EMERGENCY TELEPHONE NUMBER

Submit in duplicate and

STEP 4. OPERATION INFORMATION

LIST THE MANAGERS FOR THIS PREMISE (ENCLOSE AN ADDITIONAL SHEET IF NECESSARY )

If No, do you monitor the premises?

 Yes

Have you conducted server training since your last renewal?

 Yes

 No