DESIGNEE AUTHORIZATION FORM
I request that the individual(s) named below have designated authority to sign on my behalf in my
capacity as ______________________________________________. This authorization is effective until
revoked by me in writing.
_____________________________________________
(Print or Type Name) (Title)
_____________________________________________
(Signature)
_____________________________________________
(Date)
Authorized Designee(s)
1. ______________________________________ 1. _____________________________________
(Print or Type Designee Name) (Designee Signature)
2.
______________________________________ 2. _____________________________________
(Print or Type Designee Name) (Designee Signature)
3. ______________________________________ 3. _____________________________________
(Print or Type Designee Name) (Designee Signature)
(Title)