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  • ATC Power of Attorney

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    Jb Roqnroll
    10 Ansichten2 Seiten
    The form appoints an individual or firm as the permit holder's Attorney-in-Fact to represent them in matters before the Commission relating to their permit. It authorizes the representative to receive confidential information and act on the permit holder's behalf, but not receive refund checks. The permit holder acknowledges the representative's actions will be binding. It must be signed and notarized.

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    The form appoints an individual or firm as the permit holder's Attorney-in-Fact to represent them in matters before the Commission relating to their permit. It authorizes the representative to receive confidential information and act on the permit holder's behalf, but not receive refund checks. The permit holder acknowledges the representative's actions will be binding. It must be signed and notarized.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    10 Ansichten2 Seiten

    ATC Power of Attorney

    Hochgeladen von

    Jb Roqnroll
    The form appoints an individual or firm as the permit holder's Attorney-in-Fact to represent them in matters before the Commission relating to their permit. It authorizes the representative to receive confidential information and act on the permit holder's behalf, but not receive refund checks. The permit holder acknowledges the representative's actions will be binding. It must be signed and notarized.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Als PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    von 2

    LIMITEDPOWEROF ATTORNEY StateForm(03/11)

    INSTRUCTIONS:

    1.Typeorprintlegibly. 2.Completeallsectionsandsignbeforeanotarypublic. 3.ThisPowerofAttorneytakeseffectonthedatesignedandremainsin effectuntilrevokedinwritingandsignedbeforeanotarypublic

    Permittee(s)Name(s) d/b/aName(s) PermitNumber Address City State ZipCode Telephone# Herebyappoint(s)thefollowingasmyAttorneyinFactpursuanttoIC.30541et.seq. IndividualRepresentative/FirmCorpName Address City State ZipCode Telephone# IfFirmorCorp.listrepresentative(s)Name (a) (b) (c) (d) Iacknowledgethatthedesignatedrepresentativehastheauthoritytoreceiveconfidential informationandfullpowertoactonmybehalfinpermitmattersbeforetheAlcohol&Tobacco Commissionrelatingtotheabovepermitnumberincluding,butnotlimitedto,executingdocuments onmybehalf.Thisauthoritydoesnotincludethepowertoreceiverefundchecks.

    IndianaAlcoholandTobaccoCommission

    Iacknowledgethatactionstakenbythedesignatedrepresentativearebindingonme,myestate,my heirs,orassigns.MyAttorneyinFactisauthorizedtomakephotocopiesofthisinstrumentasis deemednecessary.Eachphotocopyshallhavethesameforceandeffectasanyoriginal. IfIamacorporateofficer,partnerorfiduciaryactingonbehalfofthePermittee,IcertifythatIhave authoritytoexecutethisPowerofAttorneyonbehalfofthePermittee. Signature Date PrintedName Title Telephone# STATEOFINDIANA ) COUNTYOF________ )SS: Beforeme,theundersigned,aNotaryPublicinandforsaidCountyandState,personallyappeared _______{nameofindividual},whoacknowledgedtheexecutionoftheforegoingLimitedPowerof Attorneythis____dayof_____. WITNESSmyhandandNotarySeal. NotaryPublic MyCommissionexpires: Residentof______County

    IndianaAlcoholandTobaccoCommission

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