Vendor_Signatory_Form.pdf

TOWN OF MOORESVILLE

CERTIFICATION OF AUTHORIZED SIGNATORY AND

ELECTRONIC SIGNATURE ROUTING FORM

***PLEASE NOTE THAT THIS FORM AND APPLICABLE SECTIONS MUST BE COMPLETED

AND NOTARIZED IN ORDER TO CONTRACT WITH THE TOWN OF MOORESVILLE. ***

Typed or Printed Legal Business Name (Same as W-9) Typed or Printed EIN #

PART I – LEGAL ENTITY INFORMATION

Check the legal entity type that is applicable to the above-named business:

_____ Sole Proprietorship – Complete Section A _____ General or Limited Partnership (LLP, PLLP) – Complete Section B _____ Corporation (Inc., Co.) – Complete Section C _____ Limited Liability Company (LLC, PLLC)—Complete Section D

State of Organization: __________________________________________________________ (Please ensure status of Good Standing or comparable from NC Secretary of State)

Street Address of Principal Office in State of Organization:

Mailing Address (if different than street address): _______________________________

For entities organized in a place other than NC, please attach current, valid certificate of authorization from the NC Secretary of State to do business in NC. If the entity is exempt from obtaining a certificate of authority, please complete the Certification of Exemption for Foreign Corporations-Section E.

Name of Registered Agent: ________________________________

Street Address of Registered Office in NC: ________________________________

Mailing Address (if different than street address): ________________________________

Please list any and all fictitious names or doing business as (dba) registrations below, along with location of registration:

PART II – ELECTRONIC SIGNATURE ROUTING INFORMATION

In order to execute documents more efficiently, the Town of Mooresville may use the electronic signature application DocuSign. By selecting “I Agree,” “I Accept,” or other similar item, button, or icon via use of a keypad, mouse, or other device, as part of the DocuSign application, 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 information on the next page to ensure documents requiring execution are routed correctly. PLEASE TYPE OR PRINT CLEARLY.

AUTHORIZED SIGNATORY – The name, title, email address and phone number indicated on the Authorized Signatory Form.

Printed or Typed Name: ________________________________________

Printed or Typed Title: ________________________________________

Printed or Typed Email: ________________________________________

ADDITIONAL AUTHORIZED SIGNATORY – The name, title, email and phone number of any additional authorized or required signatories indicated on the Authorized Signatory Form. Please indicate if required or not.

Printed or Typed Name: ________________________________________

Printed or Typed Title: ________________________________________

Printed or Typed Email: ________________________________________

Check if Required: ____

ADDITIONAL REVIEWER – The name, title, email address and phone number of any additional reviewer at the vendor, contractor, or supplier will review any documents prior to the authorized signatory executing those documents.

Printed or Typed Name: ________________________________________

Printed or Typed Title: ________________________________________

Printed or Typed Email: ________________________________________

ADDITIONAL REVIEWER – The name, title, email address and phone number of any additional reviewer at the vendor, contractor, or supplier will review any documents prior to the authorized signatory executing those documents.

Printed or Typed Name: ________________________________________

Printed or Typed Title: ________________________________________

Printed or Typed Email: ________________________________________

SECTION A – SOLE PREPRIETORSHIP

Name and Contact Information of Owner:

Name: ___________________________________ Address: ___________________________________

Phone: ___________________________________ Email: ___________________________________

I HEREBY CERTIFY that I am the sole owner of the business identified above and am authorized to sign legal documents on behalf of the business.

Signature: ________________________________________ Printed Name: ________________________________________

**NOTARY**

REQUIRED FOR SUBMITTAL

STATE OF ________________________

COUNTY OF ______________________

I, ________________________________, a notary public for the above referenced county and state, certify that ________________________________________________________ personally came before me this _____ day of ____________________, 20___ and acknowledged that he/she is the ________________________(title) of ___________________________________(entity name), a _____________________________________(type of entity), and that he/she as ______________________(title), being authorized to do so, executed the foregoing Certification of Authorized Signatory Form on behalf of _____________________________________(entity name).

Witness my hand and official seal:

______________________________________ Notarial Seal:

Signature Printed Name

SECTION B – PARTNERSHIP

Names and contact information of all general partners: (Please attach additional pages if necessary.)

Name: _____________________________ Name: __________________________ Address: _____________________________ Address: __________________________ Phone: _____________________________ Phone: __________________________ Email: _____________________________ Email: __________________________

Please attach documentation showing those with authority to sign on behalf of the partnership and any other requirements or restrictions regarding signatory authority, such as number of partners required to authorize a transaction. This may be the relevant portions of the partnership agreement (to include the first page, relevant provisions and signature pages) or a resolution signed by all general partners.

I HEREBY CERTIFY that I am a general partner of the business identified above and am authorized to sign legal documents on behalf of the business.

Signature: _________________________________________

Printed Name: _________________________________________

Signature: _________________________________________

Printed Name: _________________________________________

**NOTARY**

REQUIRED FOR SUBMITTAL

STATE OF ________________________

COUNTY OF ______________________

I, ________________________________, a notary public for the above referenced county and state, certify that ________________________________________________________ personally came before me this _____ day of ____________________, 20___ and acknowledged that he/she is the ________________________(title) of ___________________________________(entity name), a _____________________________________(type of entity), and that he/she as ______________________(title), being authorized to do so, executed the foregoing Certification of Authorized Signatory Form on behalf of _____________________________________(entity name).

Witness my hand and official seal:

______________________________________ Notarial Seal:

Signature

SECTION C – CORPORATION

Names and contact information of officers or directors with signatory authority: (Please attach additional pages if necessary.)

Name: ____________________________ Name: ______________________ Address: ____________________________ Address: ______________________ Phone: ____________________________ Phone: ______________________ Email: ____________________________ Email: ______________________

Please attach documentation showing those with authority to sign on behalf of the corporation and any other requirements or restrictions regarding signatory authority. This may be the relevant portions of the Articles of Incorporation and Bylaws (to include the first page, relevant provisions and signature pages) or a resolution signed by the directors or shareholders.

I HEREBY CERTIFY that at a duly called meeting of the Board of Directors/Shareholders of the legal business name indicated above, a corporation under the laws of the State of ______________________, was held on __________________, _____ and a resolution was passed authorizing ______________________________________________________________ to execute contracts on behalf of the corporation as its legally binding official act and deed. The execution of a document by ______________________________________________ on behalf of the corporation shall be attested by the Secretary of the corporation. I FURTHER CERTIFY that said resolution is now in full force and effect and I have attached a true copy of the same to this certification.

IN WITNESS THEREOF, I have hereunto set my hand this ____ day of ____________________, 20___.

Officer’s Signature: ________________________________________ Officer’s Printed Name: ________________________________________ Title: ________________________________________

Attest:

Corporate Secretary’s Signature: ________________________________________ Printed Name: ________________________________________

Corporate Seal:

I, ________________________________, a notary public for the above referenced county and state, certify that ________________________________________________________ personally came before me this _____ day of ____________________, 20___ and acknowledged that he/she is the ________________________(title) of ___________________________________(entity name), a _____________________________________(type of entity), and that he/she as ______________________(title), being authorized to do so, executed the foregoing Certification of Authorized Signatory Form on behalf of _____________________________________(entity name).

SECTION D – LIMITED LIABILITY COMPANY

Names and contact information of all managers (if manager managed) or all members (if member managed): (Please attach additional pages if necessary.)

Name: ___________________________ Name: _______________________ Address: ___________________________ Address: _______________________

Phone: ___________________________ Phone: _______________________ Email: ___________________________ Email: _______________________

Please attach documentation showing those with authority to sign on behalf of the corporation and any other requirements or restrictions regarding signatory authority. This may be the relevant portions of the Articles of Organization and Operating Agreement (to include the first page, relevant provisions and signature pages) or a resolution signed by the members.

I HEREBY CERTIFY that at a duly called meeting of the members of the legal business name indicated above, a LLC under the laws of the State of ______________________, was held on __________________, _____ and a resolution was passed authorizing ______________________________________________________________ to execute contracts on behalf of the corporation as its legally binding official act and deed. I FURTHER CERTIFY that said resolution is now in full force and effect and I have attached a true copy of the same to this certification.

IN WITNESS THEREOF, I have hereunto set my hand this ____ day of ____________________, Manager/Member-Manager Signature: ________________________________________

Printed Name: ________________________________________

Title: ________________________________________

Manager/Member-Manager Signature: ________________________________________

Printed Name: ________________________________________

Title: ________________________________________

**NOTARY**

REQUIRED FOR SUBMITTAL

STATE OF ________________________

COUNTY OF ______________________

I, ________________________________, a notary public for the above referenced county and state, certify that ________________________________________________________ personally came before me this _____ day of ____________________, 20___ and acknowledged that he/she is the ________________________(title) of ___________________________________(entity name), a _____________________________________(type of entity), and that he/she as ______________________(title), being authorized to do so, executed the foregoing Certification of Authorized Signatory Form on behalf of _____________________________________(entity name).

Witness my hand and official seal:

______________________________________ Notarial Seal:

Signature

SECTION E – CERTIFICATION OF EXEMPTION FOR FOREIGN CORPORATION

I , ______________________________, having been duly authorized as a signatory for _________________________(entity name) to legally bind and obligate said entity, hereby certify that I am a _________________________(title) of said entity. I furthermore represent and warrant that _____________________________________(entity name) is duly organized, validly existing and in good standing under the laws of the State of _______________________, and has full corporate power and authority to carry on its business as presently conducted.

I further certify that ________________________________________(entity name) is exempt from the requirement to obtain a certificate of authority from 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): _______________________________

Signature: ________________________________ Date:___________________

Printed Name: ________________________________

Title: ________________________________

I, _____________________________, a notary public for the above referenced county and state, certify that ____________________________________ personally came before me this day and acknowledged that he/she executed the foregoing certification on behalf of __________________________ as its ___________________________. Witness my hand and affixed seal this the _____ day of ______________________, 20_____.