20220151 Ver 1_SAMPLE_AGENT_AUTHORIZATION Clarks Road_20220211

dotloop signature verification: dtlp.us/TgjY-pCqE-oYg1
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 2 PLAN NO. PARCEL ID: 8-213-15000
STREET ADDRESS: 1332 Clarks Road, New Bern, 28562
Please print:
Property Owner: Vichhiko So
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Thomas Kiser of NorthGroup Real Estate - New Bern 4 Sale
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
1354 CLARKS RD, NEW BERN, NC 28562
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
dotloop verified
02/11/2212:11 PM EST
MX6E-YAEK-FG7B-RQVW
Authorized Signature Authorized Signature
Date: 02/11/2022
Date: