Department Of Taxation-Applicant'S Request To Release Information Form
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1STATE OF NEVADA
LAS VEGAS OFFICE
DEPARTMENT OF TAXATION
Grant Sawyer Office Building
S u i t e 1 3 0 0
1550 E. College Parkway
5 5 5 E . W a s h i n g t o n A v e n u e
Las Vegas, Nevada 89101
Suite 115
P h o n e : ( 7 0 2 ) 4 8 6 - 2 3 0 0
Carson City, Nevada 89706-7937
F a x : ( 7 0 2 ) 4 8 6 - 2 3 7 3
Phone: (775) 687-4820 • Fax: (775) 687-5981
RENO OFFICE
In-State Toll Free: 800-992-0900
KENNY C. GUINN
4 6 0 0 Kietzke Lane
Building O, Suite 263
Governor
Web Site:
Reno, Nevada 89502
P h o n e : ( 7 7 5 ) 6 8 8 - 1 2 9 5
DAVID P. PURSELL
F a x : ( 7 7 5 ) 6 8 8 - 1 3 0 3
Executive Director
APPLICANT'S REQUEST TO RELEASE INFORMATION:
RE:
The above referenced business/person has applied for a Nevada Motor Vehicle Fuel Dealer's License. As part of the
application process, the Nevada Department of Taxation requires certain information in order to conduct a
background investigation and compile a credit history.
You are authorized to provide the Nevada Department of Taxation any and all information it may request. This
includes, but is not limited to, checking and/or savings account balances and history, lines of credit, credit history,
length of association and payment history.
A reproduction of this request by photocopy, facsimile, or similar process, shall be for all intents and purposes as
valid as the original.
Your prompt reply to the Nevada Department of Taxation is appreciated.
Authorized Signature
Date
Name and Title (please type or print)
NOTARY:
State of
, County of
,
On this _______ day of
, _______ ,
personally
appeared before me, whose identity I proved on the basis of satisfactory evidence to be the signer of the above
instrument, and he/she acknowledged that he/she executed it.
Seal:
Notary Public
NEVADA DEPARTMENT OF TAXATION REPRESENTATIVE:
Signature
Date
23-Apr-97
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