Agency of Record Authorization Form

Agency of Record Authorization Form
Please complete this form to authorize an agency of record relationship. All information provided will be used solely for the purpose of establishing and confirming this authorization.
Client Company Name
Client Contact Name
First NameLast Name
Client Email Address
example@example.com
Agency Company Name
Agency Contact Name
First NameLast Name
Agency Email Address
example@example.com
Scope of Authorization (describe services or areas covered)
Effective Date of Authorization
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorized Signature
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Should be Empty: