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Fillable Printable Limited Power of Attorney State Form - Indiana

Fillable Printable Limited Power of Attorney State Form - Indiana

Limited Power of Attorney State Form - Indiana

Limited Power of Attorney State Form - Indiana

IndianaAlcoholandTobaccoCommission
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)thefollowingasmyAttorney–inFactpursuanttoIC.30541et.seq.
IndividualRepresentative/FirmCorpName
Address
City
State ZipCode
Telephone#
IfFirmorCorp.listrepresentative(s)Name
(a)
(b)
(c)
(d)
Iacknowledgethatthedesignatedrepresentativehastheauthoritytoreceiveconfidential
informationandfullpowertoactonmybehalfinpermitmattersbeforetheAlcohol&Tobacco
Commissionrelatingtotheabovepermitnumberincluding,butnotlimitedto,ex
ecutingdocuments
onmybehalf
.Thisauthoritydoesnotincludethepow
ertoreceiverefundchecks.
IndianaAlcoholandTobaccoCommission
Iacknowledgethatactionstaken bythedesignatedrepresentativearebindingonme,myestate,my
heirs,orassigns.MyAttorney‐inFactisauthorizedtomakephotocopiesofthisinstrumentasis
deemednecessary.Eachphotocopyshallhavethesameforceandeffectasanyorigi
nal.
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
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