Authorized_Signatory_&_Electronic_Signature_Routing_Form.pdf

Town of Mooresville Authorized Signatory & Electronic Signature Routing Form

Part I – Business Information

Legal Business Name (Same as W-9 & COI) EIN #

Address of Principal Office:

Contact Person:

Name ________________________________

Email ________________________________

Phone ________________________________

Check business legal entity type:

Sole Proprietorship General or Limited Partnership (LLP, PLLP) Limited Liability Company (LLC, PLLC) Corporation (Inc., Co.)

Please check the appropriate box if your business is exempt from the requirement to register with the North Carolina Secretary of State under N.C.G.S. § 55-15-01(b) by reason of carrying on any one or more of the following activities as indicated below:

Soliciting or procuring orders, whether by mail or through employees or agents or otherwise, where such orders require acceptance without this State before becoming binding contracts;

Transacting business in interstate commerce;

Conducting an isolated transaction completed within a period of six months and not in the course of a number of repeated transactions of like nature;

Selling through independent contractors;

Other (please explain and cite the relevant statute): ____________________________________________ dddddddddddddd

Part II – Signatory & Routing Information

To execute documents more efficiently, the Town uses the electronic signature application DocuSign. By using the application as part of the contract process, vendors, contractors, and suppliers consent to be legally bound by the terms and conditions of those documents and that such act constitutes a signature as if actually signed in writing.

Please complete the fields below (Type or Print Clearly) to ensure documents are routed correctly:

Authorized Signatory – The name, title, email address, and signature who is authorized to execute contracts on behalf of your organization:

I HEREBY CERTIFY that I am authorized to sign legal documents and to execute contracts on behalf of the organization as its legally binding official act and deed.

Name: ________________________________________

Title: ________________________________________

Email: ________________________________________

Signed: ________________________________________

Additional Authorized Signatory – The name, title, email address, and signature of an additional authorized or required signatory. Please indicate if required or not.

I HEREBY CERTIFY that I am authorized to sign legal documents and to execute contracts on behalf of the organization as its legally binding official act and deed.

Signed: ________________________________________

Check if Dual Signature is Required

Reviewers – If necessary, the name, title, and email address who will review documents prior to the authorized signatory executing those documents.

Name: ________________________________________

Legal Cousel Review Receives Copy During Execution

Legal Cousel Review Receives Copy During Execution