New Alcoholic Beverage Retailers Permit Application Page 7
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13WAIVER AND AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN:
I authorize you to furnish the Alcoholic Beverage Control Division, State Tax
Commission, with any and all information that you may have concerning me, my
work record, my reputation, and my military service records. You may allow
inspection of records by, and copies of these records may be provided to, an
authorized
representative
of
the
Alcoholic
Beverage
Control
Division.
Information of a confidential or privileged nature may be included. Your reply will
be used by the Commission in determining my fitness and eligibility to be granted
an Alcoholic Beverage Control Permit.
A reproduction of this request by Xerox or similar process shall be for all intents
and purposes as valid as the original.
I hereby release you, your organization and others from liability or damage which
may result from furnishing the information requested.
_____________________________
_____________________
APPLICANT’S SIGNATURE
DATE
WITNESSES’ SIGNATURES
_____________________________
_____________________________
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Parent category: Financial