Authorization Of The Proposed Backer Legal Entity For Release Of Financial Information

DCPLC-authbus Rev 3/08 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION Telephone: (860) 713-6210 Email: liquor.control@ct.gov Web Site: www.ct.gov/dcp Authorization of the Backer Legal Entity for Release of Financial Information This form must be completed by a duly authorized representative of the backer business identified in item #1 below: A. BUSINESS INFORMATION 1. Name of Backer Business Entity: 2. Federal Employer ID Number (FEIN): City: State: Zip code: 3. Address of Backer Business Entity: (street & number) 4. Name of Authorized Representative: (last, first, middle) 5. Business Title of Representative: 6. Address of Authorized Representative: (street & number) City: State: Zip code: 7. Telephone Number of Authorized Representative: ( ) - Fax Number: ( ) - 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 nowledge: Signature of duly authorized representative of the backer: _________________________________________________________________________ Title: _________________________ Date: ________________________ American LegalNet, Inc. www.FormsWorkflow.com