Limited Power Of Attorney Page 2
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2I 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 original.
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.
Signature
Date
Printed Name
Title
Telephone #
STATE OF INDIANA
)
COUNTY OF ________
) SS:
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.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Notary Public
My Commission expires:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Resident of ______County
Indiana Alcohol and Tobacco Commission
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