Town of
Elcho
APPLICATION FOR OPERATOR’S (BARTENDER’S) LICENSE
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□ 2 Year
Operator’s License - $25.00
□ 60 Day
Provisional License - $9.00
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□ Renewal Applicant □ New Applicant
Payment MUST Accompany
Application
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SECTION 1 – APPLICANT INFORMATION
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Applicant Name (Last, First, MI)
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Maiden Name
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Street Address
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City
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State
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Zip
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Driver’s License Number
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Social Security Number
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State License Issued In:
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Date of Birth
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Sex
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Home Phone Number
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Cell Phone Number
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Name and Address of establishment you will be selling alcohol
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SECTION 2 – CONVICTION RECORD
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Have you EVER been convicted of a felony?
□ YES □ NO
If Yes; when, where and what type of violation? (Please be specific)
Have you EVER been convicted of a misdemeanor or ordinance violation? □ YES □ NO
If Yes; when, where and what type of violation?
Do you have any PENDING criminal
cases against you for violating ANY State Law or Local Ordinances?
□ YES □ NO
OFFENSE: __________________________________________________________________________________________
Name of Law Enforcement Agency: _____________________________________________________________________
(Attach additional pages or continue on back of this page
if needed)
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SECTION 3 – RENEWAL INFORMATION
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I Have Completed a Responsible
Beverage Servers Training Course:
ID #
(Include a copy of your RBSTC Card)
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I am Presently Enrolled in a
Responsible Beverage Servers Training Course at: which is scheduled to start on:
/ /
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I am Exempt from this provision
because I have continuously held an Operator’s License in the following municipality:
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SECTION 4 – PENALTY NOTICE
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I,
the undersigned, make application for an Operator’s License as provided by
Wisconsin State Statute 125.17. Under penalty of law, I swear that the information provided in this application is true and correct to the best of my knowledge and belief. I understand that any false
information made as part of this application may be cause for denial.
Signature
_________________________________________________________________ Date:________________________
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FOR OFFICE USE ONLY
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Date Application Received
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Approve
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Deny
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By
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Reason
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Date Sent for Criminal Record
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Date Criminal Record Recvd
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Date Issued
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Expiration Date
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License Number
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;) ;) ;)
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 Updating...
ĉ Elcho Town, Jul 28, 2016, 2:36 PM
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