Granting Authority to Act Affirmation
________________________________________ affirms the truth of the following:
(Applicant Name)
1. I am the _______________________ of ___________________________________
(State relationship to business) (Name of business as it appears on your Business or
Partnership Certificate, or Certificate of Incorporation
or Filing Receipt. If you are applying for an
Individual-based license, please enter “N/A”.)
which is located at ____________________________________________ and whose
(Street Address, Borough, State, and Zip Code)
telephone number and email address are ______________ and ________________.
(Area code & Number) (Email Address)
2.
I hereby authorize _______________________ of ___________________________
(Full name of designated (Full name of representative’s business)
representative)
who maintains an office/resides at _______________________________________
(Street Address, Borough, State, and Zip Code)
and whose telephone number and email address are ______________________ and
(Area code & Number)
__________________ to represent me before the license, permit, or certificate
(Email Address)
issuing Agency in regard to the preparation and submission of an application for the
following license(s), permit(s) or certificate(s):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. I understand that I will be legally bound by the representations made in said
applications and will be held responsible by the license, permit, or certificate issuing
Agency for any inaccuracies or misrepresentations.
4. I understand that this affirmation will expire 180 days from the date I sign and date
this form.
5. I understand that I may revoke (withdraw) the Granting Authority to Act by calling
311 and asking for assistance revoking a Granting Authority to Act. A 311 call taker
will advise me on how to notify the relevant issuing Agencies about revocation, and I
will be responsible for notifying the relevant issuing Agencies of each application to
which the revocation applies. Revocations may only be made prior to issuance of the
applicable license, permit or certificate.
______________________________ ______________________________ ____________________
Signature Print Name Date
