Granting Authority Form – Fill Out and Use This PDF

Gr a n t in g Au t h or it y t o Act Af f ir m a t ion

________________________________________ affir m s t he t r ut h of t he follow ing:

( Applicant Nam e)

1 . I am t he _______________________ of ___________________________________

( St at e r elat ionship t o business)	( Nam e of business as it appear s on y our Business or
	Par t ner ship Cer t ificat e, or Cer t ificat e of I ncor por at ion
	or Filing Receipt . I f y ou ar e apply ing for an
	I ndiv idual- based license, please ent er “ N/ A” . )

w hich is locat ed at ____________________________________________ and w hose

( St r eet Addr ess, Bor ough, St at e, and Zip Code)

t elephone num ber and em ail addr ess ar e ______________ and ________________ .

( Ar ea code & Num ber )( Em ail Addr ess)

2 . I her eby aut hor ize _______________________ of ___________________________

w ho m aint ains an office/ r esides at _______________________________________

( St r eet Addr ess, Bor ough, St at e, and Zip Code)

and w hose t elephone num ber and em ail addr ess ar e ______________________ and

( Ar ea code & Num ber )

__________________ t o r epr esent m e befor e t he license, per m it , or cer t ificat e

( Em ail Addr ess)

issuing Agency in r egar d t o t he pr epar at ion and subm ission of an applicat ion for t he

follow ing license( s) , per m it ( s) or cer t ificat e( s) :

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

3 . I under st and t hat I w ill be legally bound by t he r epr esent at ions m ade in said applicat ions and w ill be held r esponsible by t he license, per m it , or cer t ificat e issuing Agency for any inaccur acies or m isr epr esent at ions.

4 . I under st and t hat t his affir m at ion w ill ex pir e 180 day s fr om t he dat e I sign and dat e t his for m .

5 . I under st and t hat I m ay r ev ok e ( w it hdr aw ) t he Gr ant ing Aut hor it y t o Act by calling 311 and ask ing for assist ance r ev ok ing a Gr ant ing Aut hor it y t o Act . A 311 call t ak er w ill adv ise m e on how t o not ify t he r elev ant issuing Agencies about r ev ocat ion, and I w ill be r esponsible for not ify ing t he r elev ant issuing Agencies of each applicat ion t o w hich t he r ev ocat ion applies. Rev ocat ions m ay only be m ade pr ior t o issuance of t he applicable license, per m it or cer t ificat e.

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Sig n a t u r e	Pr in t N a m e	D a t e