Attachment 0003_eAuthorization Application.pdf

Attachment 0003 e-Authorization Application Form (all entries must be typed)

Applicant:

Name

Title/Position

Telephone

Email

Company/Organization (employer):

Name

Address

Telephone

Email

Applicant certification:

I, , hereby certify that the above data is correct to the best of my knowledge and that I am authorized to request and obtain an e-Authorization account and submit invoices or vouchers to the Federal Highway Administration (FHWA) via the Delphi e-Invoicing system for costs incurred on behalf of my employer in support of grants, cooperative agreements, contracts, task/delivery orders, or purchase orders, awarded to my employer by the FHWA.

Date

Concurrences:

First level supervisor

Second level supervisor

Return this form to the FHWA Contract/Agreement Specialist at: FHWA-WFLHD, Attn: Simplified Acquisitions, 610 E 5th Street, Vancouver, WA 98661-3801 or email to WFL.Purchasing@dot.gov.

This application form will be submitted to ESC for processing. You will receive instructions to complete your application and receive a unique user ID and password via email from ESC. If more than one person is to be designated, each person must submit an application form and will receive instructions and their own unique user ID and password. User IDs and passwords may not be shared.