AUTHORIZATION AND CONSENT TO RELEASE INFORMATION
Form 12
City Clerk’s office 303-538-7230
9500 Civic Center Drive
Thornton, Colorado 80229-4326
APPLICANTS & MANAGERS – COMPLETE BELOW AND SIGN
Name of Individual (please print):
Position:
Trade Name of Establishment:
Address of Establishment:
THE FOLLOWING PARAGRAPH DOES NOT APPLY TO MANAGERS
¾ I, as an applicant for the above referenced liquor/beer license, hereby authorize release of information
pertaining to my financial qualifications in conjunction with the paragraphs listed above. I hereby consent to
and authorize the release of any and all personal or business books, records, checkbooks, bank statements
and records, financial data, balance sheets, income accounts, forms and all other applicable data and
information relative to my credit standing and business reputation by any person or entity having possession
or control thereof to any person presenting a signed copy of this Authorization and Consent to Release
Information, or a true copy of a signed copy thereof, upon the express condition, however, that said release is
limited to an investigation conducted pursuant to the aforesaid licensing and operation thereunder, but this
consent shall continue to operate so long as above-named licensee shall hold said license, if granted, and for
the term or terms of any renewals or extension thereof.
THE FOLLOWING TWO PARAGRAPHS APPLY TO ALL APPLICANTS & MANAGERS
¾ As an applicant for a Liquor/Beer License or a Manager’s Registration before the Thornton Local Licensing
Authority, I am required to furnish information concerning my moral, educational, and mental qualifications. In
this regard, I hereby authorize the Thornton Police Department to make any and all appropriate inquiries
regarding the above-enumerated qualifications. Moreover, I authorize those people or organizations selected
by the Thornton Police Department to release any and all information of a confidential or privileged nature.
¾ I hereby release you, your organization or others from any liability or damage, which may result from
furnishing the information requested. I further authorize the Thornton Police Department and Local Licensing
Authority to discuss, in a public forum, any and all findings in regard to my moral, educational, and character
qualifications, should I wish to proceed to that stage of the process with my application. I understand that any
information or records obtained from you or by the City may become public records available upon request by
the public.
Signature Date Signed
Subscribed and sworn to before me by:
in the County of Adams, State of Colorado, this day of , 20
Notary Public:
SEAL
My Commission Expires:
(authority/forms/city liquor forms/form 12/9.2004)
