Limited Power Of Attorney

LIMITED POWER OF ATTORNEY State Form (03/11) INSTRUCTIONS: 1. Type or print legibly. 2. Complete all sections and sign before a notary public. 3. This Power of Attorney takes effect on the date signed and remains in effect until revoked in writing and signed before a notary public Permittee(s) Name(s) d/b/a Name(s) Permit Number Address City State Zip Code Telephone # Hereby appoint(s) the following as my Attorney ­inFact pursuant to IC. 30541 et. seq. Individual Representative/Firm Corp Name Address City State Zip Code Telephone # If Firm or Corp. list representative(s) Name (a) (b) (c) (d) I acknowledge that the designated representative has the authority to receive confidential information and full power to act on my behalf in permit matters before the Alcohol & Tobacco Commission relating to the above permit number including, but not limited to, executing documents on my behalf. This authority does not include the power to receive refund checks. Indiana Alcohol and Tobacco Commission American LegalNet, Inc. www.FormsWorkFlow.com  I acknowledge that actions taken by the designated representative are binding on me, my estate, my heirs, or assigns. My Attorney inFact is authorized to make photocopies of this instrument as is deemed necessary. Each photocopy shall have the same force and effect as any original. If I am a corporate officer, partner or fiduciary acting on behalf of the Permittee, I certify that I have authority to execute this Power of Attorney on behalf of the Permittee. Signature Date Printed Name Title Telephone # STATE OF INDIANA ) COUNTY OF ________ ) SS: Before me, the undersigned, a Notary Public in and for said County and State, personally appeared _______{name of individual}, who acknowledged the execution of the foregoing Limited Power of Attorney this ____day of _____. WITNESS my hand and Notary Seal. Notary Public My Commission expires: Resident of ______County Indiana Alcohol and Tobacco Commission American LegalNet, Inc. www.FormsWorkFlow.com