BLS 700-002 (10/01/19)
Signature Title Date
Print name City and state where signed
This authorizaon remains in eect unl revoked in wring by either party. Keep a copy for your les. To revoke this
authorizaon, 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 ocer, or LLC member or manager in ocial records held by Washington State, or I
have aached documentaon (e.g., power of aorney, annual report, executor) that grants me the authority to sign.
ATTN:
1. My informaon (This informaon 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 informaon for any me period.
Any informaon for this me period
Only listed informaon for this me period
Authorized names
I authorize the Department of Revenue to share my condenal licensing informaon as indicated.
Use this form to authorize the Department of Revenue to share your condenal licensing informaon with a third party.
Condenal Licensing Informaon Authorizaon
2. Share my condenal licensing informaon with the individual(s)/company listed below.
month/quarter and year to month/quarter and year
month/quarter and year to month/quarter and year
Informaon 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 instrucons on page 2.
If you are authorizing an enre company or a Legislator’s oce, add the words “and sta.” If authorizing specic
people, add addional name(s) in the Authorized names secon.
Business name
UBI number Phone
Mailing address City ST Zip
Email Fax
*To update your business record, go to hps://dor.wa.gov and log in to your account.