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APPLfCATfON FOR NEW OR TRANSFER PERMIT r <br /> State Form(TSA) <br /> INSTRUCTIONS:i. Type or print legibly. <br /> 2. Submit in duplicate. Include paymant <br /> S. Do not complete shadedareas. <br /> 4. Mall to the address at the and of this application Corm. <br /> S. if there Is no opening for this applied permit or there is an omission,thls application will <br /> be returned <br /> This Permit Type wld allow you to sail? This permit Type is for? Application type? <br /> ❑ Beer ❑ On-premise consumption(Retailer) ❑ New application <br /> ❑ Wine ❑ Oft-premise consumption(Dealer) ❑ Transfer owner <br /> ❑ Liquor ❑ Other(Specify Below) ❑ Transfer locafon <br /> ❑ Transfer stock <br /> Please briefly describe your business that qualifies you for this permi(type Permit number(Required for transfers) <br /> This ownership entity Is:(Check one) <br /> ❑ Sale Owner ❑ Limited Partnership ❑ Municipality <br /> ❑ Simple Partnership ❑ Limited Liability Partnership ❑ Club Association <br /> ❑ Corporation ❑ Limited Liability Company ❑ Club Corporation <br /> Business entity mwdng this application Business telephone number <br /> Doing business as(D&1) <br /> Location where alcoholic beverages will be dispensed(nwnbar and street) Premise telephone number <br /> CRY 1 Town State ZlP code <br /> Indiana retall merchanrs certificate number Horne telephone number(including area code) Email address <br /> General Quastlons Pant 1 <br /> 1. The proposed premise is located in what county? <br /> 2. Is the proposed permit premise located inside the corporate limits of a city I town? D Yes ❑ No <br /> 3. If yes,please name the incorporated city I town. <br /> 4, If no,please name the unincorporated community which has been known by that name for <br /> more than ten years.(This Is only required for a beer or a beer and wine application.) <br /> 3. Is there at least 240 feet between this premise and any church or school? ❑ Yes ❑ No <br /> if no mall receptacle at this location aryou wish to have your correspondence sent to another address: <br /> Name <br /> Address <br /> City,State,Zip <br /> General Questions Part 2 <br /> 1. Do you understand that you must apply for a Federal ID number? ❑ Yes ❑ No <br /> 2. Do you understand that you must apply for a Federal Stamp from the Bureau of Alcohol,Tobacco, <br /> and Flrearrns(BATF)? ❑ Yes ❑ No <br /> 3. Does the permittee have an interest In any distiller,vintner,farm winery,rectifier,brewer,primary <br /> source of supply,or wholesaler permit? ❑ Yes ❑ No <br /> 4. As owner do you manage the premise? © Yes ❑ No <br /> If no,please complete ft Manager's.Questionnaire and attach It to this application. <br /> 5. Do you sell tobacco products? ❑ Yes ❑ No <br /> 8. Do you know that an Excise Officer may enter,inspect,and search your permit premise without <br /> a warrant or other process to determine if you are complying with the provisions of the Indiana <br /> alcoholic beverage laws f rules? ❑ Yes ❑]No <br /> 7. Do you have the right to possess(lent;lease,mortgage.or own)the permit promise for the term <br /> ofthe permit? ❑ Yes ❑ <br />