Clerk Authorization Form
Complete this Clerk Authorization Form to authorize a clerk to perform specified actions on behalf of your organization.
Organization Name
*
Authorized Clerk's Full Name
*
First Name
Last Name
Clerk's Email Address
*
example@example.com
Clerk's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Permitted Actions
*
Submit documents
Collect correspondence
Sign routine paperwork
Access specified records
Other
Authorization Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization Expiry Date (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorized Representative's Full Name
*
First Name
Last Name
Authorized Representative's Signature
*
Submit Authorization
Submit Authorization
Should be Empty: