Limited Power Of Attorney
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2LIMITED 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
Permittee(s) Name(s)
d/b/a Name(s)
Permit Number
Address
City
State
Zip Code
Telephone #
Hereby appoint(s) the following as my Attorney –in‐Fact pursuant to IC. 30‐5‐4‐1 et. seq.
Individual Representative/Firm Corp Name
Address
City
State
Zip Code
Telephone #
If Firm or Corp. list representative(s) Name
(a)
(b)
(c)
(d)
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, executing documents
on my behalf. This authority does not include the power to receive refund checks.
Indiana Alcohol and Tobacco Commission
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Parent category: Financial