SECTION II
A
UTHORIZATION AND RELEASE
AUTHORIZATION FOR EXAMINATION AND RELEASE OF INFORMATION
FOR USE IN ASSESSMENT OF A GIFTING STATEMENT IN THIS ALCOHOLIC BEVERAGE / GAMBLING LICENSE
APPLICATION
I, (person gifting), do hereby authorize a review, full disclosure and
release of any and all records concerning me to any duly authorized officer, agent or employee of the Montana
Department of Justice, Gambling Control Division or Montana Department of Revenue, Liquor Division that they
determine relates to the applicant’s qualifications for gambling and/or alcoholic beverage licensure, whether the
records are of a public, private, or confidential nature, with the following understanding:
1. The information reviewed, disclosed, or released may be used by the State of Montana to determine
whether to issue a gambling and/or alcoholic beverage license to the applicant in accordance with MCA
§23-5-176 and/or §16-4-401.
2. I release the providers of the information collected pursuant to this authorization of any liability under state
or federal privacy laws and further release the State of Montana, its officers, agents and employees from
any liability that may be incurred as a result of the collections and lawful use of the information.
3. If this authorization is not sufficient to obtain access to certain records, I may be requested to execute some
other appropriate authorization or release and that any failure to do so may be taken into consideration by
the Montana Department of Justice, Gambling Control Division or Montana Department of Revenue, Liquor
Control Division in its review of this gambling and/or alcoholic beverage license application.
4. I understand that I may revoke this authorization in writing at any time and that the Montana Department
of Justice, Gambling Control Division or Montana Department of Revenue, Liquor Control Division, may take
any such revocation into consideration in its review of this gambling and/or alcoholic beverage license
application.
5. The validation period for this authorization is not to exceed one year and may be reaffirmed if required by
the Montana Department of Justice or Montana Department of Revenue.
6. A photocopy or electronic copy of this authorization has the same force and effect as the original.
Signature of Person Gifting Date
Type or Print Name Phone
State of ______________________ On this day of , 20 ,
County of _____________________ personally appeared
before me a Notary Public for the State of .
Notary Signature
Print Name of Notary
My Commission Expires
Mail complete application, required documents to:
Gambling Control Division
PO Box 201424
Helena, MT 59620
www.revenue.mt.gov/home/liquor
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