Delegated Authority Policy Form
Document a new delegation, a change to existing authority, or a revocation.
Request action
*
New delegation
Change existing delegation
Revoke delegation
Delegator name
*
First Name
Last Name
Delegator role and department
*
Delegate name
*
First Name
Last Name
Delegate role and department
*
Delegated authority scope
*
Limits and exclusions
*
Effective date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End date or review date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Delegator authorization signature
*
Submit
Submit
Should be Empty: