Authorization To Disclose And Furnish Copy Of Record {LIQ 144-50}

Licensing and Regulation Division PO Box 43098 Olympia WA 985043098 Phone: (360) 6641600 FAX: (360) 753-2710 www.lcb.wa.gov ____________________________________________ Trade Name ____________________________________________ License Number ____________________________________________ UBI Number AUTHORIZATION TO DISCLOSE AND FURNISH COPY OF RECORD To: Financial Institution(s); Utility Providers(s); Business (es); engaged in lending, arranging or closing loans and real estate transactions This form authorizes release of any and all information, including photocopies, to the Washington State Liquor Control Board (WSLCB) or its representatives, regarding either myself or any business account with which I am connected, and to furnish information concerning my financial responsibility. The purpose of this authorization is to aid the WSLCB in the financial investigation of the application for a license. RCW 66.24.010(2) If this authorization is not sufficient to obtain access to certain records, it is understood that I may be requested to execute some other appropriate authorization or release and that any failure to do so may be taken into consideration by the WSLCB in its review of the license application. I understand and give my permission for a credit check to be completed if it is deemed necessary as part of the financial investigation. A copy of this authorization will constitute a duplicate original and as such shall have the same effect and authorization as the original. I understand that I may revoke this authorization in writing at any time and the WSLCB may take any such revocation of this authorization into consideration in its review of the license application. I release the providers and users of the information collected pursuant to this authorization from any liability under state or federal privacy laws and further release the state of Washington, its officers, agents and employees from any liability, which may be incurred as a result of the collection and use of the information. This authorization will automatically expire upon completion of the investigation. Signature __________________________________ Print Name _________________________________ Date ________________________ State of Washington, County of ____________________________________________________________ I certify that I know or have satisfactory evidence that _____________________________ is the person who appeared before me, and said person acknowledged that (he/she) signed this instrument and acknowledged it to be (his/her) free and voluntary act for the uses and purposes mentioned in the instrument. Dated Signature of Notary Public LIQ 144-50-7/15 *LCB LIQ144* American LegalNet, Inc. www.FormsWorkFlow.com Seal or Stamp Print Name Title My appointment expires: American LegalNet, Inc. www.FormsWorkFlow.com