Fillable Printable Limited Power of Attorney State Form - Indiana

Limited Power of Attorney State Form - Indiana

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IndianaAlcoholandTobaccoCommission

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LIMITEDPOWEROF ATTORNEY

StateForm(03/11)

INSTRUCTIONS: 1.Typeorprintlegibly.

2.Completeallsectionsandsignbeforeanotarypublic.

3.ThisPowerofAttorneytakeseffectonthedatesignedandremainsin

effectuntilrevokedinwritingandsignedbeforeanotarypublic

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Permittee(s)Name(s)

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d/b/aName(s)

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PermitNumber

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Address

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City

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State

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ZipCode

Telephone#

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Herebyappoint(s)thefollowingasmyAttorney–in‐FactpursuanttoIC.30‐5‐4‐1et.seq.

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IndividualRepresentative/FirmCorpName

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Address

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City

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State ZipCode

Telephone#

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IfFirmorCorp.listrepresentative(s)Name

(a)

(b)

(c)

(d)

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Iacknowledgethatthedesignatedrepresentativehastheauthoritytoreceiveconfidential

informationandfullpowertoactonmybehalfinpermitmattersbeforetheAlcohol&Tobacco

Commissionrelatingtotheabovepermitnumberincluding,butnotlimitedto,ex

ecutingdocuments

onmybehalf

.Thisauthoritydoesnotincludethepow

ertoreceiverefundchecks.

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IndianaAlcoholandTobaccoCommission

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Iacknowledgethatactionstaken bythedesignatedrepresentativearebindingonme,myestate,my

heirs,orassigns.MyAttorney‐in‐Factisauthorizedtomakephotocopiesofthisinstrumentasis

deemednecessary.Eachphotocopyshallhavethesameforceandeffectasanyorigi

nal.

IfIamacorporateofficer,partnerorfiduciaryactingonbehalfofthePermittee,IcertifythatIhave

authoritytoexecutethisPowerofAttorneyonbehalfofthePermittee.

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Signature Date

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PrintedName 

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Title Telephone#

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STATEOFINDIANA  )

COUNTYOF________  )SS:

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Beforeme,theundersigned,aNotaryPublicinandforsaidCountyandState,personallyappeared

_______{nameofindividual},whoacknowledgedtheexecutionoftheforegoingLimitedPowerof

Attorneythis____dayof_____.

WITNESSmyhandandNotarySeal.

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‐‐‐‐‐‐‐‐‐‐‐

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‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

NotaryPublic

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MyCommissionexpires:

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Residentof______County 

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