Form Wld 101 - Wyoming Liquor Division

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WLD 101 (5/98)
WYOMING LIQUOR DIVISION
th
1520 East 5
ST
Cheyenne, Wyoming 82002-0110
FAX(307) 777-6255
DATE:
E-MAIL ADDRESS:
WLD CUSTOMER NO:
BUSINESS PHONE:
FAX PHONE:
LICENSEE NAME:
D/B/A:
(Applicant Name)
(Doing Business As)
PREMISE ADDRESS:
(Street/Rural Route)
(City)
(State)
(Zip)
MAILING ADDRESS:
(Street/Rural Route/PO Box)
(City)
(State)
(Zip)
AUTHORIZATION TO PLACE LIQUOR ORDERS (ANYONE NOT LISTED BELOW WILL NOT BE ALLOWED TO PLACE ORDERS)
1.
(Printed Name)
(Signature)
2.
(Printed Name)
(Signature)
3.
(Printed Name)
(Signature)
4.
(Printed Name)
(Signature)
5.
(Printed Name)
(Signature)
(
)
OWNER AUTHORIZATION - Printed Name
(OWNER AUTHORIZATION - Signature
)
WLD 101M
(5/98)
DATE:
In order to keep our records current, please fill in the following information:
WLD CUSTOMER NO:
BUSINESS PHONE:
FAX PHONE:
LICENSEE NAME:
D/B/A:
(
Applicant Name)
(Doing Business As)
PREMISE ADDRESS:
(Street/Rural Route)
(City)
(State)
(Zip)
MAILING ADDRESS:
(Street/Rural Route/PO Box)
(City)
(State)
(Zip)
E-MAIL ADDRESS:
AUTHORIZATION OF MANAGER
I AUTHORIZE
(Manager Printed Name)
(Manager Signature)
TO ACT ON MY BEHALF ON ACTIONS INDICATED BELOW:
ADD AND REMOVE PERSONNEL AUTHORIZED TO PLACE LIQUOR ORDERS.
REQUEST SALES INFORMATION FROM LIQUOR DIVISION, INCLUDING DOLLAR PURCHASES.
NOTE: A new form is required if there is a change of manager. Please notify us immediately in writing if current manager is no
longer authorized.
(OWNER AUTHORIZATION - Printed Name)
(OWNER AUTHORIZATION - Signature)

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