20 S CASL~1.docm

INSTRUCTIONS: All Contractors (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who are authorized as legal representatives of the Contractor who are authorized to sign contracts and other legally binding documents on the Contractor’s behalf. In addition to this listing, additional proof of authority to sign contracts on behalf of the Contractor, and/or proof of authenticity of signature is required by Contractor’s submission of a completed Contractor Authorized Signature Verification Form (CASV).

NOTICE: Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the Contractor challenging the existence of a valid Contract due to an alleged lack of authority to execute the document by the signatory.

For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.

I certify that I am the President, Chief Executive Officer, Chief Fiscal Officer, Corporate Clerk, Legal Counsel or other authorized officer of the Contractor. I hereby certify that the names of the individuals identified on this listing are current as of the date of execution below and that these individuals are authorized to sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated to any state department with which the Contractor does business whenever the authorized signatories are no longer authorized to sign contracts with the Commonwealth or whenever new signatories are designated.

Signature: Date:

Print Name: Title:

Telephone: Fax: Email:

[Listing cannot be accepted unless all of the information is completed. The Contractor must also complete and submit a Contractor Authorized Signature Verification Form (CASV), as appropriate.] Issued May 2004

) CONTRACTOR AUTHORIZED SIGNATORY LISTING (CASL)

Executive Office of Labor and Workforce Development

CONTRACTOR LEGAL NAME:

CONTRACTOR VENDOR/CUSTOMER CODE:

DBA (if applicable):

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