Authorization to Represent Form

Authorization to Represent Form
Use this form to grant another person or entity the authority to act on your behalf in specified matters.
Your Full Name
First NameLast Name
Your Contact Information (Email and Phone)
Your Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Full Name of Representative
First NameLast Name
Representative's Contact Information (Email and Phone)
Representative's Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Relationship to the Representative
Scope of Authorization (Please specify the matters or actions the representative is authorized to handle)
Authorization Period: Start Date
MonthDayYear
Date
Authorization Period: End Date
MonthDayYear
Date
Additional Notes or Limitations (Optional)
Signature of Authorizer
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Date of Signing
MonthDayYear
Date
Should be Empty: