Operator'S License Application Form

APPLICATION FOR OPERATOR’S LICENSE

To the local governing body of the TOWN OF LAKE MILLS, JEFFERSON COUNTY, WISCONSIN

I, _________________________________________________________________________________________________

(PRINT first, Middle initial and last name of applicant),

of ________________________________________________________________________________________________

(PRINT place of employment, license use and address of place of employment)

Make application for an operator’s license under s. 125.17, Wis. Stats., to sell alcohol beverages in a place operated for the sale of alcohol beverages, and I agree that

I will comply with all laws, resolutions, ordinances and regulations, state, federal and local, affecting the sale of alcohol beverages, if a license is granted to me.

I certify that I am a person of 18 years of age and that I have successfully completed a responsible beverage server-training course.

Date of Birth _____________ Signature of Applicant _______________________________________________________

Answer the following questions fully and completely:

Residential address of applicant: _______________________________________________________________________

Is this application for a:

regular operator’s license

or

manager’s license

(CIRCLE ONE)

Is application new or renewal?________, If renewal (within the past 2 years held a Class A, Class B or Class C license, or a

manager’s or operator’s permit), where was the privilege previously obtain ____________________________________

As required by Wis. Stat. Sec. 125.17(6), have you completed the alcohol beverage server-training course? (CIRCLE ONE)

YES

NO

If so, where? _________________________________________________________________________________________________________

PLEASE PROVIDE A VALID CERTIFICATION OF COMPLETION OF TRAINING COURSE WITH THIS APPLICATION IF NOT CURRENTLY ON

FILE WITH THE TOWN OF LAKE MILLS

Have you been convicted of any felony or of violating any law of the State of Wisconsin or the United States?

(CIRCLE ONE)

YES

NO

If yes, date of such conviction:________________________________________________________________

Name of Court: _______________________________, Nature of offense: __________________________________________________________________________

Have you been convicted of violating any license law or ordinance regulating the sale of Fermented Malt Beverages or

Intoxicating Liquors?

YES

NO

If yes, date of violation: ______________________________________________________________________

Nature of violation: _______________________________________________________________________________________________________________________

Have you been known by any other name in the last 5 years due to marriage, divorce, adoption etc?

If so please list previous names: ________________________________________________________________________

Driver’s License# ________________________________________ Social Security Number: _______-______-________

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PLEASE HAVE THIS APPLICATION NOTARIZED BELOW

STATE OF WISCONSIN

JEFFERSON County.

_________________________ (Name of Applicant) being first duly sworn on oath says that (s)he is the person who

made and signed the forgoing application for an operator’s license; that all the statements made by the applicant are

true.

Signature of Applicant: _______________________________________________

Subscribed and sworn to before me

Payment or receipt is submitted herewith, showing the payment of

This, ______day of __________, 20 ___

the sum of $30.00 per regular operator license application or $25.00

________________________________

per manager’s license, to the Town Treasurer, in payment of this

Notary Public, __________ County, WI

license.

My Commission expires: ____________

…………………………………………………………………………………………………………………………...………………………………………………………………

Checks are to be made out to and mailed with application to: Town

Office Use Only:

of Lake Mills, 1111 South Main Street, Lake Mills, Wi 53551

Date received by Town Clerk ___________________ Date reported to Town Board _______________________Back ground check completed on_________________

Date License granted __________________________Date issued _____________________________________ License # ____________________________________

Fee received _________________________________ in the amount of $________________________ Check # ____________________________________________

Signature of Town Clerk ________________________________________________________________________________________________

Updated 04-14