Updated Agent Authorization Form.pdf

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT 81 8 82 PB 5 PG 109
LOT N0. PLAN NO. PARCEL ID:
STREET ADDRESS:
49268 Smit Water Rd, Albermarie, NC. 28001
Please print:
Property Owner: J- 'z- rL r c H ,'s
Property Owner:
6576-01-35-7005
The undersigned, registered property owners of the above noted property, do hereby authorize
Alex Ricketts of Anchored Design
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this pen -nit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
5311 Love Mill Road: Monroe, NC, 28110
704-242-1565
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date:
Au orized nature
Date: 3. a L2 P Oa