Form 1285 V3 - Power Of Attorney Page 2
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2The Power of Attorney shall be effective upon receipt thereof by the Department of Revenue
and shallcontinue until cancelled by filing with the department an instrument properly executed and reciting
such cancellation.
IN WITNESS WHERE OF, the undersigned has caused these present to be execute, for benefit of the
principal namebelow.
Please check the following licenses which you hold or are applying for:
Business Tax License(s)
Tax License Number(s) if previously assigned
Sales/Use Tax License
Manufacturers License
Wholesalers License
Contractors’ Excise Tax License
Special Licenses
Alcohol Wholesalers License
Tobacco Distributor License
Accounting or Reporting Firm By:
Principle and Licensee By:
Company Name
Company Name
FEIN or SS#
FEIN or SS#
Signature of Owner/Legal Rep.
Signature of Owner/Legal Rep.
Title
Title
Address-Mailing
Address-Mailing
City/State
City/State
Phone Number
Phone Number
State of:
County of:
On this
day of
, before the undersigned, a Notary of the Public for the
State of
personally appeared
known to
be the person whose name is subscribed to the within instrument, and acknowledge to me that
he
executed the same in capacity as shown.
IN WITNESS WHEREOF, I have set my hand and seal this
day
of
,this certificate above written.
Notary Public
My commission expires:
CLEAR FORM
PRINT FOR MAILING
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Parent category: Legal