NH Liquor

Authorized Signature for Purchase/Pickup of Liquor and Wine

State of New Hampshire Liquor Commission
P.O. Box 503
Concord, New Hampshire 03301-0503
Phone # (603) 230-7053 Fax # (603) 271-2375


License Number:
Business Name:
Business Address:
City:
State: Zip:
Billing Name:
Billing Address:
City:
State: Zip:
Contact Name:
Phone Number:

An authorized signer for the Purchase/Pickup of liquor or wine must be 21 years of age or older

AUTHORIZED SIGNER

Print Name: who is 21 years of age or older is authorized to sign for the purchase and/or pickup of liquor at State Liquor Store#: assigned to supply liquor for resale under the provisions of RSA 176:10-A and Liquor 900.

THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL REVOKED IN WRITING. ALL REVOCATIONS TO BE MAILED TO THE NEW HAMPSHIRE LIQUOR COMMISSION, STORRS STREET, P.O. BOX 503, CONCORD, NEW HAMPSHIRE 03302-0503

If the person signing this authorization is an officer in a corporation, please attach a copy of the minutes authorizing him to execute this document.


Print Signer's Name

_____________________________________ / _________________
Signature of signer / Date



Print Licensee Name

_____________________________________ / _________________
Signature of licensee / Date