MISSOURI DEPARTMENT OF TRANSPORTATION
PO BOX 270, 830 MODOT DRIVE, JEFFERSON CITY, MO 65102-0270
CHANGE OR ADDITION OF COMPANY CONTACT
In order to request a change or addition of company contact, the requestor must be authorized on the account to make
changes. In order for this form to be valid it must be signed by an authorized company official and notarized by an
individual appointed and commissioned as a notary public in the state of Missouri.
SECTION 1. CUSTOMER TYPE (Select all that apply)
SECTION 2. COMPANY INFORMATION
NAME OF COMPANY CONTACT AUTHORIZED TO MAKE CHANGES
Add the following contact person to the account listed above:
E-MAIL ADDRESS (*ONLY ONE E-MAIL ADDRESS IS ALLOWED PER ACCOUNT*)
*Additional contacts may be added using a separate sheet.
SECTION 4. REMOVE CONTACT
Remove the following contact person from the account listed above:
*Additional contacts may be removed using a separate sheet.
Signature of Authorized Company Contact
NOTARY PUBLIC EMBOSSER SEAL OR
BLACK INK RUBBER STAMP
COUNTY (OR CITY OF ST LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
NOTARY PUBLIC NAME (TYPED OR PRINTED)