20240240 Ver 1_AGENT_AUTHORIZATION_FORM (1) signed_20240206

SAMPLE AGENT AUTHORIZATION FORM

PROPERTY LEGAL DESCRIPTION:

LOT NO. ______________ PLAN NO. ____________ PARCEL ID: ________________________

STREET ADDRESS: _____________________________________________________________

_____________________________________________________

Please print:
Property Owner: ________________________________________________________________

Property Owner: ________________________________________________________________

The undersigned, registered property owners of the above noted property, do hereby authorize

__________________________________, of ________________________________________
(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):

_________________________________________________________________

Telephone: _____________________________

We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.

__________________ __________________ _________________ __________________
Authorized Signature Authorized Signature

Date: _______________________________ Date: _______________________________

Document ID: df2dc6d523d957ef7b4f33b3fd95d270ff50301055e400cd9fe285a6eb648409
Signer ID: J7PEZDSO11...Signer ID: 6EIDYOJF11...
02/06/2024 PST 02/06/2024 PST
Signature Certificate
Envelope Ref:0888ec99b78f2d8294b8ab574e5dc2b193e4b695
Author: Michael Anderson Creation Date: 06 Feb 2024, 13:15:19, PST Completion Date: 06 Feb 2024, 13:30:13, PST
Document Details:
Name: AGENT_AUTHORIZATION_FORM
Type:
Document Ref: df2dc6d523d957ef7b4f33b3fd95d270ff50301055e400cd9fe285a6eb64
8409
Document Total Pages: 1
Document Signed By:
Name: Robert Schultz
Email: [e-mail]
IP: 150.195.50.58
Location: EASTPOINT, FL (US)
Date: 06 Feb 2024, 13:28:16, PST
Consent: eSignature Consent Accepted
Security Level: Email
Signer ID :6EIDYOJF11...
Name: Tiffany Schultz
Email: [e-mail]
IP: 150.195.50.58
Location: EASTPOINT, FL (US)
Date: 06 Feb 2024, 13:30:13, PST
Consent: eSignature Consent Accepted
Security Level: Email
Signer ID :J7PEZDSO11...
Document History:
Envelope Created Michael Anderson created this envelope on 06 Feb 2024, 13:15:19, PST
Invitation Sent Invitation sent to Tiffany Schultz on 06 Feb 2024, 13:17:10, PST
Invitation Sent Invitation sent to Robert Schultz on 06 Feb 2024, 13:17:10, PST
Invitation Accepted Invitation accepted by Robert Schultz on 06 Feb 2024, 13:27:25, PST
Signed by Robert Schultz Robert Schultz signed this Envelope on 06 Feb 2024, 13:28:16, PST
Invitation Accepted Invitation accepted by Tiffany Schultz on 06 Feb 2024, 13:29:30, PST
Signed by Tiffany Schultz Tiffany Schultz signed this Envelope on 06 Feb 2024, 13:30:13, PST
Executed Document(s) successfully executed on 06 Feb 2024, 13:30:13, PST
Signed Document(s) Link emailed to [e-mail]
Signed Document(s) Link emailed to [e-mail]
Signed Document(s) Link emailed to [e-mail]