Attachment 4 - Contractor Authorized Signatory Listing Form~1.pdf
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- Solicitation number
- BD-26-1049-GIC00-07GIC-130036
- Issued by
- Massachusetts
About this file
This is a Contractor Authorized Signatory Listing Form issued jointly by the Massachusetts Office of the Comptroller and Operational Services Division for use by Commonwealth departments in managing contractor authorization documentation. The form requires all contractors, except sole proprietors or individual contractors, to provide a listing of authorized legal representatives who may execute contracts and legally binding documents on the contractor's behalf. The form accommodates multiple signatories with designated fields for up to four authorized representatives, including their names, titles, signatures, phone numbers, and email addresses. Contractors must certify that listed signatories are current as of the execution date and maintain a duty to immediately update the listing whenever signatories are terminated, retire, or have their responsibilities changed, as well as when new signatories are designated. A copy of the completed listing must be attached to the record copy of any contract filed with the Commonwealth department.
The form accepts three types of electronic signatures: traditional wet signatures in ink, hand-drawn electronic signatures created via mouse or touch screen, or digital signatures generated through tools such as Adobe Sign or DocuSign. Typed text, computer-generated cursive, and electronic symbols are not acceptable signature formats. The Commonwealth reserves the right to publish the names and titles of authorized signatories as public records, though contractors are instructed to exclude personally identifiable information such as bank account numbers, Social Security numbers, driver's licenses, and home addresses from attached documentation. Acceptance of payment under a contract constitutes a waiver of any contractor defense challenging the validity of the contract based on alleged lack of actual authority by the signatory. The form also requires certification by a responsible authorized officer of the contractor and prohibits self-certification by a single signer listed on the form.
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Text version
Commonwealth of Massachusetts
CONTRACTOR AUTHORIZED SIGNATORY LISTING
This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth Departments when another form is not prescribed by regulation or policy.
Signature for Corporation (C or S), Partnership, Trust/Estate, Limited Liability Company, State and Local Government Entity
(must match Form W-9 tax classification)
Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number or Social Security Number)
INSTRUCTIONS: Any Contractor (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 can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf. In addition to this listing, any state department may require additional proof of authority to sign contracts on behalf of the Contractor, or proof of authenticity of signature (a notarized signature that the Department can use to verify that the signature and date that appear on the Contract or other legal document was actually made by the Contractor’s authorized signatory, and not by a representative, designee or other individual.)
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.
There are three types of electronic signatures that will be accepted on this form: 1) Traditional “wet signature” (ink on paper); 2) Electronic signature that is either: a. hand drawn using a mouse or finger if working from a touch screen device; or b. An upload picture of the signatory’s hand drawn signature; 3) Electronic signature affixed using a digital tool such as Adobe Sign or DocuSign. Typed text of a name not generated by a digital tool, computer generated cursive, or an electronic symbol are not acceptable forms of electronic signature.
Authorized Signatory Name
Signature (As it will appear on contract or other documents)
Title Phone Number
Email Address
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 actual authority to execute the document by the signatory.
I certify that I am a responsible authorized officer of the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals identified on this listing are current as of the date of execution 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 above retire, are otherwise terminated from the Contractor’s employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with the Commonwealth or whenever new signatories are designated.
Please note: You cannot self-certify your own signature as a single signer listed above.
Signature Date
Print Name Phone Number
Title Email Address
A copy of this listing must be attached to the “record copy” of a contract filed with the department.
| Signature for Corporation (C or S), Partnership, Trust/Estate, Limited Liability Company |
| (must match Form W-9 tax classification) |
| Contractor Legal Name: |
| Signature: |
| Date: |
| Print Name: |
| Phone Number: |
| Title: |
| Email Address: |
| Contractor Vendor/Customer Code: |
| Signature 1: |
| Title 1: |
| Phone Number 1: |
| Email Address 1: |
| Authorized Signatory Name 1: |
| Authorized Signatory Name 2: |
| Authorized Signatory Name 3: |
| Authorized Signatory Name 4: |
| Signature 2: |
| Signature 3: |
| Signature 4: |
| Title 2: |
| Title 3: |
| Title 4: |
| Phone Number 2: |
| Phone Number 3: |
| Phone Number 4: |
| Email Address 2: |
| Email Address 3: |
| Email Address 4: |
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