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
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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
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Signature of signer / Date
Print Licensee Name
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Signature of licensee / Date