State Form 43 PDF Details

State Form 43 is a crucial and oftentimes overlooked form that serves as an important part of many legal procedures. Whether you are involved in litigation or just navigating the complex world of law, it is essential to understand what role this document may play in your case. In this blog post, we will discuss the essentials about State Form 43 and equip you with the knowledge necessary to make informed decisions when using it for legal purposes. From definitions and filing requirements to best practices, our goal is to provide clear answers so you can move forward confidently on your path towards success.

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