Form 13 - Noninstitutional Loan And Authorization For Examination Form 13 Page 3

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MONTANA DEPARTMENT OF JUSTICE
GAMBLING CONTROL DIVISION
AUTHORIZATION FOR EXAMINATION AND RELEASE OF INFORMATION
FOR USE IN ASSESSMENT OF A NONINSTITUTIONAL LENDER DISCLOSED IN THIS
GAMBLING LICENSE APPLICATION
I,______________________________________, a noninstitutional lender, do hereby authorize a review, full
disclosure and release of any and all records concerning me that the Montana Department of Justice properly
determines relate to the applicant’s qualifications for gambling licensure to any duly authorized officer, agent or
employee of the Montana Department of Justice, Gambling Control Division, whether the records are of a public,
private, or confidential nature, with the following understanding:
1. The information reviewed, disclosed, or released may be used by the State of Montana to determine
whether to issue a gambling license to the applicant in accordance with Mont. Code Ann. § 23-5-176.
2. I release the providers of the information collected pursuant to this authorization from any liability under
state or federal privacy laws and further release the State of Montana, its officers, agents and employees
from any liability that may be incurred as a result of the collections and lawful use of the information.
3. If this authorization is not sufficient to obtain access to certain records, it is understood that I may be
requested to execute some other appropriate authorization or release and that any failure to do so may be
taken into consideration by the Montana Department of Justice, Gambling Control Division, in its review of
this gambling license application.
4. I understand that I may revoke this authorization in writing at any time and that the Montana
Department of Justice, Gambling Control Division, may take any such revocation of this authorization into
consideration in its review of this gambling license application.
5. This authorization is valid for a period not to exceed one year and may be reaffirmed if required by the
Montana Department of Justice.
6. A photocopy of this authorization has the same force and effect as the original.
7. This authorization may only be used with the specific written approval of the Gambling Control Division
Administrator and the Attorney General.
Signature of Applicant: _______________________________________________Date: _________________________
Type or Print Name of Applicant: _____________________________________________________________________
On this ___________day of ________________________ 20___________
Personally appeared ___________________________________________
Before me a Notary Public for the State of __________________________
N O T A R Y S E A L
_________________________________________(Notary Signature)
______________________________________ (Print Name of Notary)
My Commission Expires ______________(Month, Day & Four Digit Year)
3
Form 13 Rev. 03/08

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