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Name of manager¢ast first middle initial) Social sec u4ly Number <br /> ATC Employee permit number Expiration date Age Isex Data of birth Height Weight <br /> El Mafe El Female <br /> Home address(numberand street) <br /> 04,state,zip <br /> Are you a citizen of the united States? ❑ Yes ❑ No <br /> Are you at least twenty-one(21)years old? ❑ Yes ❑ No <br /> Is it true that you are not an officer or employee of a person engaged in the alcoholic beverage traffic,which person Is a non-resident <br /> of this state,or is engaged In carrying on any phase of manufacture of,traffic in,or transportation of alcoholic beverages without a ❑ Yes ❑ No <br /> permit when one Is required? <br /> Are you a State law enforcement officer,or a non-elected officer of;municipal corporation or government subdivision charged with ❑ Yes ❑ No <br /> any duty or function In the enforcement of Alcoholic Beverage Laws. <br /> Has your alcoholic beverage permit been revoked,within one year prior to the date of thts application for a permit? ❑ Yes ❑ No <br /> 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? <br /> (Unless the application was denied by a reason of a procedural or technical defect.) ❑ Yes ❑ No <br /> Are you now,and have you been for the last fire years a continuous and bona fide resident of the State of Indiana? If no,does the ❑ Yes ❑ No <br /> permit premise you are managing have a minimum annual gross food sales ofat least$100,0007 <br /> 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, Yes ❑ No <br /> directly or indirectly,through ownership of stock or otherwise?.If yes.,explain below: <br /> Have you been convicted of a felony? N yes,attach places and dates of arrest,court of record,and conviction and attach relevant ❑ Yes ❑ No <br /> court record. <br /> Have you been convicted of a violation of the Indiana Alcoholic Beverage Laws,rules,regulations,or orders of the Commission? If Yes [] No <br /> yes,explain on a separate attachment <br /> Signatures or manager or agent(s)referred to in this schedule <br /> WSTRUCTWNS: Applicant must submit four(4)drawings on letter size paper(812'x 117. These drawings must show dimensions and identiScations of <br /> any existing family room(s),seating afrangement(s),bafiroom(s),service bar(s),dance floor area(s),kitchen area(s),restrooms,storage <br /> and office areas,exits,and alcoholic beverage display areas for all types of permits. Please sign and date each drawing. <br /> ❑Yes ❑No If a restaurant or a restaurant located In a hotel or motel,will anyone under the age of 21 be guests to the permit premise? <br /> tithe answer to the above question Is'yes,'it should be understood that there must be COMPLETE SEPARATION ofthe barroom from the <br /> room or rooms where Individuals under the age of 21 will be present <br /> ❑Yes ❑No Are you requesting approval for limited separation? <br /> NOTE. <br /> ALL DRAWINGS MUST BE'APPROVED BY THE COMMISSION BEFORE THE PERMIT IS ISSUED. WE RECOMMEND YOU RECEIVE APPROVAL <br /> BEFORE CONSTRUCTION BEGINS. CONTACT YOUR LOCAL EXCISE DISTRICT OFFICE. <br /> tPisase attach all drawinas to this anoticalionl <br />