Fill - Condenal Licensing Informaon Authorizaon (Washington)

BLS 700-002 (10/01/19)

Signature Title Date

Print name City and state where signed

This authorizaon remains in eect unl revoked in wring by either party. Keep a copy for your les. To revoke this

authorizaon, write “Revoke” across the front of this form and return it to the Department as indicated in step 4.

3. My signature

I declare, under penalty of perjury, that I am authorized to sign this form. I am listed as the real property owner or as the

business owner, partner, corporate ocer, or LLC member or manager in ocial records held by Washington State, or I

have aached documentaon (e.g., power of aorney, annual report, executor) that grants me the authority to sign.

ATTN:

1. My informaon (This informaon will not be used to update your business record.*)

Individual or company name

Mailing address City ST Zip

Phone Fax

Place an X in the appropriate box below:

Any informaon for any me period.

Any informaon for this me period

Only listed informaon for this me period

Authorized names

I authorize the Department of Revenue to share my condenal licensing informaon as indicated.

Use this form to authorize the Department of Revenue to share your condenal licensing informaon with a third party.

Condenal Licensing Informaon Authorizaon

2. Share my condenal licensing informaon with the individual(s)/company listed below.

month/quarter and year to month/quarter and year

Informaon to be shared

4. Fax to 360-705-6699, email to bls@dor.wa.gov or mail to address on back.

For licensing assistance or to request this document in an alternate

format, please call 360-705-6741. Teletype (TTY) users may use the

Washington Relay Service by calling 711.

See instrucons on page 2.

If you are authorizing an enre company or a Legislator’s oce, add the words “and sta.” If authorizing specic

people, add addional name(s) in the Authorized names secon.

Business name

UBI number Phone

Mailing address City ST Zip

Email Fax

*To update your business record, go to hps://dor.wa.gov and log in to your account.

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BLS 700-002 (10/01/19)

Condenal Licensing informaon

Licensing informaon is condenal and cannot be shared with anyone without express permission. By compleng this

form, you are authorizing the Department to share your condenal licensing informaon with the person(s) you name.

This request may cover all condenal licensing informaon or it may be limited to certain informaon and/or periods of

me. In secon 2, please describe the specic informaon you want the Department to share and the periods covered

by this authorizaon.

ATTN: (If you are working with a Revenue employee)

If you are working with a Revenue employee, write the employee’s name on the ATTN: line on the boom of page 1 of

this form and return the form as instructed.

Otherwise, send this form to:

Fax 360-705-6699

Email bls@dor.wa.gov

Mail Dept. of Revenue

Business Licensing Service

PO Box 47475

Olympia, WA 98504-7475

Quesons? Call the Department at 360-705-6741.

Authorizaon for Condenal Licensing Informaon

Page 2

Washington State Department of Revenue

PO Box 47475

Olympia, Washington 98504-7475

Phone: 360-705-6741

Fax: 360-705-6699

Website: dor.wa.gov

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