NC0075388 Partial

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E. Submitter Signature
The Submitter (electronic signature applicant) is a user other than the Responsible Official who submits
this agreement to request to sign reports electronically. The Submitter is given signatory authority by an
individual identified as the Responsible Official by the Owner/Organization to sign reports and other
information and to accept electronic documents.
I, Juanita James (printed name), am authorized by the Responsible Official name in
this document, who does have the authority under the applicable standards, to enter into this agreement �/
for Tro Consultants — Pleasant Cove Home (Chvnef 1Organization Name).
By submitting this application, I, Juanita James (printed name), have read, understand, and
accept the terms and conditions of this Electronic Signature Agreement. I certify under penalty of law that
I have personally examined and am familiar with the information submitted in this application and all
attachments and that, based on my inquiry of those persons immediately responsible for obtaining the
information contained in the application, I believe that the information is true, accurate and complete. I
am aware that there are significant penalties for submitting false information, including the possibility of
fine and imprisonment.
Subrotter Signature Title Date
office cr iiemi>net 828-697-0063
Email Address Phone Number
*email will be the primary method or contact for the electronic submittal process so it is important to have an accurate email
available at all times
If you are a current eDMR submitter please provide your User Id:
User Id
Subscribed and sworn to before me this (1) day of bc km)4A , 20 .
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NCDWR Electronic Submittal Agreement Version 1 Page 5