Application For Transfer In Officers/stock Of Alcoholic Beverage Retailers Permit (Page 6 of 6) in pdf

Application For Transfer In Officers/stock Of Alcoholic Beverage Retailers Permit Page 6

Accounts Payable (ex. credit cards) ..... $_______________

Taxes Payable .................................... $_______________

Other .................................................

$_______________

Long Term Liabilities (debts due in more than one year)

Notes Payable ....................................

$_______________

Mortgages Payable ............................. $_______________

Other .................................................

$_______________

Total Liabilities ...... $_______________

WAIVER AND AUTHORIZATION TO RELEASE FINANCIAL INFORMATION

TO WHOM IT MAY CONCERN:

I hereby request and authorize you to furnish the Alcoholic Beverage Control

Division, State Tax Commission, with any and all information you may have

concerning me or my financial records and copy such records, whether or not

such documents would otherwise be protected from disclosure by any

constitutional, statutory, or common law privilege. I agree to indemnify and hold

harmless the person to whom this request is presented from all manner of

actions arising out of or by reason of complying with this request.

A reproduction of this request by Xerox or similar process shall be for all intents

and purposes as valid as the original.

This request shall expire twelve (12) months from date of signing.

_________________________________

_____________________

APPLICANT’S SIGNATURE

DATE

WITNESSES’ SIGNATURE

_________________________________

Application For Transfer In Officers/stock Of Alcoholic Beverage Retailers Permit Page 6