Design Professional Digital Signature
Affidavit
( i.e. – engineers, architects, land architects,
surveyors)
Applicant
Name:
Company
Name:
Design
Professional’s
License
#
:
Phone:
Email
Address:
The email address listed above will be your ‘Authorized Email Address’.
Authorization. The Undersigned architect or engineer (“Undersigned”) understands that (s) he is authorizing Town of Fort Myers Beach through its
Permitting and Plan Review Departments to accept documents electronically using the seal and signature appearing below. Upon receiving any
documents through IWORQ, uploaded by any IWORQ user, which have been authorized by the seal and signature below, the Town of Fort Myers Beach
will assume that the documents were authorized by the Undersigned. It is the Undersigned’s obligation to maintain its information in a secure
environment to ensure that all documents electronically submitted are in fact authorized by the Undersigned.
Termination. If the Undersigned believes the security of the digital signature has been compromised or simply wishes to terminate the use of such
signature, (s) he must file a written notice termination with the Town of Fort Myers Beach Office, 2525 Estero Blvd, Fort Myers Beach, FL. 33931, OR
permits@fmbgov.com.
With good cause and without notice, Town of Fort Myers Beach at its discretion may terminate the Undersigned’s authorization to electronically
submit documents to IWORQ.
Governing Law. The Undersigned understands that the electronic signing and sealing of documents is governed by Florida law, Electronic submissions
must meet state law requirements as described in the Florida Statutes Chapter 471.025, 481.221, and 668.001‐006. Specifically, with reference to Florida
Statutes Chapter 481 and Florida Administrative Rule 61G1‐16.005 for Architects, or Florida Statutes Chapter 471 and Florida Administrative Code Rule
61G15‐ 23.003 for Engineers.
By signing this document, you are not only agreeing to the foregoing but certifying that: Any willful falsification of any information contained herein is
grounds for disqualification.
DIGITALSIGNATUREWITHNAME,CERTIFICATIONNUMBER(PE,AA,ETC.)and“STATE OFFLORIDA”VISIBLE
DIGITALSIGNATURESERIALNUMBERorNAME
OFCERTIFICATIONAUTHORITY
VALIDITYENDDATEOFDIGITALSIGNATURE
PLACE APPLICANTS
RAISED, WET OR
ELECTRONIC SEAL IN
THIS AREA
I, _____ (Property Owner), hereby certify that
_______________________________________ is my authorized agent/representative of the property described herein. All answers to the
questions in this registration and any supplementary information attached to and made part of this registration is honest and
true.
Signature of Property Owner
Typed or printed name of Property Owner
