Connecticut > Statewide > Department Of Consumer Protection > Liquor Control Division

Authorization Of The Backer Legal Entity For Release Of Financial Information - Connecticut

Authorization Of The Backer Legal Entity For Release Of Financial Information Form. This is a Connecticut form and can be used in Liquor Control Division Department Of Consumer Protection Statewide .
 Fillable pdf Last Modified 11/9/2010
Get this form for FREE as a print-only pdf

DCPLC - Backer Auth Rev 3/17 STATE OF CONNECTICUT LIQUOR CONTROL DIVISION Telephone: (860) 713-6210 Email: dcp.liquorcontrol@ct.gov Web Site: www.ct.gov/dcp/liquorcontrol DEPARTMENT OF CONSUMER PROTECTION Authorization of the Proposed Backer Legal Entity for Release of Financial Information This form must be completed by a duly authorized representative of the backer identified in Section D of the new application: A. BUSINESS INFORMATION 1. Name of Backer Business Entity: 2. Address of Backer Business Entity: (street & number) City: State: Zip code: 3. Name of Authorized Representative: (last, first, middle) 4. Business Title of Representative: 5. Address of Authorized Representative: (street & number) City: State: Zip code: 6. Telephone Number of Authorized Representative: 7. Fax Number: 8. Email Address B. AUTHORIZATION: 1. I authorize any agent from the State of Connecticut, Department of Consumer Protection to obtain any information related to the business entity identified in item #1 above from financial or lending institutions, credit bureaus, consumer reporting agencies, licensing agencies and retail business establishments or individuals. 2. I agree that no individual or entity shall be held liable for use of this authorization to determine my suitability for a liquor permit. C. PERSONAL CERTIFICATION: I certify, under penalty of law that the information provided in this authorization is true to the best of my knowledge. _____________________________________________________________________ Signature of duly authorized representative of the backer _________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. amendment to complaint
  2. information subpoena
  3. stipulation of discontinuance
  4. Petition for Administration
  5. deposition subpoena
  6. Request for entry of default
  7. bill of costs
  8. durable power of attorney
  9. Form Interrogatories-General
  10. Preliminary Change of Ownership Report

Bookmark and Share