03-26-12 Council Agenda & Packet

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Complete Name Sodat Security Number DOS Citizen of US ❑Yes ❑No Address(number and sheet d(,stale,ZIP) Nature of Interest Percent of ownership ❑Sole Owner ❑Corporate President ❑Stockholder ❑Partner ❑.Corporate Secretary ❑Club Officer Complete Name Social Security Number DOB Citizen of U3 ❑Yes ❑No Address(number andstredt,dty,slate,ZIP) Nature of interest Percent of ownership ❑Sole Owner ❑Corporate President ❑Stockholder ❑Partner ❑Corporate Secretary ❑Club Officer Complete Name Social Security Number 008 Citizen of US ❑Yes ❑No Address(numberandstreet dly,stale,ZIP) Nature of Interest Percent of ownership ❑Sole Owner ❑Corporate President ❑Stockholder ❑Partner ❑Corporate secretary ❑Club Officer Complete Name Sodal Security Number DOS Citizen of US ❑Yes ❑No Address(number andshedt dly,state,ZIP) Nature of interest Percent of ownerstttp []Sole Owner ❑Corporate President ❑Stockholder ❑Partner Corporate-Secretary ❑Club Officer If you need more space,please attach additional sheets. You must meet specific requfrements to hold certain types of permits. Please answer only the following questions that are applicable to your permit application. LIQUOR RETAILER ❑Yes ❑No is the proposed permit premise located in an Incorporated city having a population of less than 5,000? Q Yes ❑No If the answer Is yes,have you attached to the application the enabling ordinance from the city consenting to the issuance of liquor retailer's permits? CATERING HALL ❑ Yes []No Are you applying for a special three-way catering hail permit that will allow you to sell alcoholic beverages for on-premise consumption only on a premise that is used only for private catered events and has accommodations for at least 250 Individuals? CLUBS [I Social Club ❑ Fraternal Club If you are applying for a club permit,please check the appropriate box- 0 Yes ❑No If a social club,does your association or organization meet the general requirements of IC 7.1-3-20-1? (] Yes[]No If your club permit premise is outside the corporate limits,do you meet the requirements of 4C 7.1-3-20-37 HOTEL ❑ Yes[]No , p you are applying as a hotel,do you meet the general requirements of IC 7.1-3-20-18? HISTORIC DISTRICT ❑ Yes❑No If you are applying for historic district permit,Is the restaurant located in a facility that Is on the National Register of Historic Places or is it located within the boundaries of a historic district established by ordinance? If yes,you must submit the appropriate verification. AIRPORT,REDEVELOPMENT:1tIVERFRONT,RAILWAY STATION,CULTURAL CENTER Yes❑No If you are applying for a permit authorized by IC 7.1-3-20-16,do you meet the requirements fbr the designated permit? Specify the type of permit you are applying for NOTE. if you are applying for a municipal riverfront development permit you mast also submit a latter indicating that the statutory requirements have been met and the mayor's approval of the permit.