State Form 43 PDF Details

In the realm of regulatory compliance, the State Form 43 stands out as a critical document for individuals seeking a Temporary Employee Permit in Indiana. Authorized by the State Board of Accounts in 2006, this form serves as an application for those wishing to obtain permission to work in environments where alcohol and tobacco are sold, but under a temporary status. The form meticulously gathers general information about the applicant, including personal identification details and contact information, which are deemed mandatory for proceeding with the application. Furthermore, it delves into the background of the applicant with a series of pointed questions aimed at uncovering any past convictions related to operating while intoxicated, any present sentences being served for similar offenses, unsettled tax liabilities with the Indiana Department of Revenue, and previous denials, revocations, or suspensions of alcoholic beverage permits or employee's permits. In addition to these inquiries, applicants are reminded of the legal responsibilities that come with serving alcohol, the rights of excise officers to inspect premises without warrant, and the enforceable nature of alcoholic beverage laws in Indiana. A nominal fee accompanies the submission of the form, emphasizing the formality and legal weight behind obtaining such a permit. Lastly, the application demands an affirmation of truth and accuracy under the penalty of perjury, underscoring the seriousness with which the State of Indiana regards the responsible sale and service of alcoholic beverages.

QuestionAnswer
Form NameState Form 43
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesINDIANA, application for employee permit state form 43 indiana, 2006, enforceable

Form Preview Example

TEMPORARY EMPLOYEE PERMIT APPLICATION

State Form 43 (R4/4-06)

Approved by State Board of Accounts, 2006

●This permit may be issued for use at the location covered by and during the time period of Temporary permit only.

INDIANA ALCOHOL & TOBACCO COMMISSION

302 W. Washington Street, Rm. E114

Indianapolis, Indiana 46204

Temporary Permit Section (317) 234-4315

Web page: http://www.IN.gov/atc

STEP 1. GENERAL INFORMATION

Name of applicant (first, middle initial, last) (please print)

 

 

Daytime telephone number

 

E-mail address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (number and street)

 

 

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number (Mandatory per IC 4-1-8-1 (a) (b))

Sex

 

 

Height (ft. in.)

Weight (lbs.)

 

Date of birth (month, day, year)

Age

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Temporary Permit Number:

 

 

 

Date(s) of Temporary Permit:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location where Temporary Permit is to be used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 2. BACKGROUND QUESTIONS - READ CAREFULLY PRIOR TO ANSWERING

 

 

 

 

Have you ever been convicted of operating while intoxicated in Indiana or of a similar charge in any other state? (If yes, please list the

Yes

No

month, day, year, and location of your conviction(s) ______________________________________________

 

 

 

 

 

Yes

No

Are you currently serving a sentence, including any term of probation for operating 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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you had an application for an alcoholic beverage permit or employee's permit denied, revoked, or suspended within the last 5 years?

Yes

No

If yes, explain ______________________________________________________________________

 

 

 

 

 

 

Yes

No

Have you ever had a drivers license in any other state? If so, you must attach a copy of your driving record from that state.

 

 

 

 

Yes

No

Do you know that it is a Class B Misdemeanor, punishable by up to 6 months in jail and a $1,000 fine, for knowingly serving an intoxicated person?

 

 

 

Yes

No

Do you know that an excise officer may enter, inspect, and search a permit premises in which you work without a warrant and you must produce

 

 

proof of your temporary employee 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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 3. FEE AND PAYMENT SCHEDULE

 

 

 

 

Temporary Employee Permit

(Fee $5.00)

 

 

 

 

 

 

 

 

 

You may work on your receipt at the Temporary event noted on this application.

 

 

 

 

 

Payment by mail may be made by money order, business check, cashier's check, or certified check. Cash accepted only if hand delivered to ATC office.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 4. SIGNATURE AND AFFIRMATION

I certify that this application was completed by myself. I affirm under penalties of perjury that I am at least 21 years of age and that all information provided on this form is true and correct. I understand that it is a 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)

 

OWI Background Check

No OWI

OWI

 

OWI

No record on file

 

Eligible

Ineligible

For Office Use Only

 

 

 

Conviction Date(s)

Eligible Date

Revealed

YES

NO

Initial & Date

 

 

 

 

 

 

 

 

 

 

 

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