Signatory Request Form

Signatory Request Form

Parties and Purpose

Requestor Name:

Organization Name:

Recitals

WHEREAS, the Requestor seeks to obtain formal authorization to sign certain documents on behalf of the Organization, and the Organization requires a written record that defines the scope and limits of such authority;

WHEREAS, the Organization is willing to appoint the requested individual as an authorized signatory for specified categories of documents and financial commitments subject to the terms, limitations, and internal controls set forth in this form;

WHEREAS, the parties intend for this Signatory Request Form, once approved and signed by the designated authorized representative of the Organization, to constitute the formal delegation of signatory authority described herein.

Requested Signatory Details

Individual Corporation LLC Government / Public Entity

Scope of Authority (Scope of Work)

Describe the documents, transaction types, and monetary limits the signatory is authorized to execute. Include any required countersignature or approval conditions.

Specific Authorization Parameters

Authorization Type (check all that apply):

Execute contracts Approve invoices Sign checks / disbursements Execute NDAs Other (specify in Scope of Authority)

Financial limit per transaction: $

Payment Terms

When applicable, the Organization agrees to reimburse or make payments arising from transactions executed by the signatory in accordance with the Organization’s standard payment procedures and the specific limits set forth herein.

Late payment fee or interest rate (if applicable):

Term and Termination

Effective Start Date:    Term End Date (if any):

Either party may terminate this delegation upon written notice to the other. Required notice period (days):

Upon termination, the signatory must immediately cease exercising delegated authority and return or secure all documents, checkbooks, identification cards, and access devices provided to effect the delegated duties.

Confidentiality

The signatory shall keep confidential and shall not disclose to any third party any non-public information obtained in connection with the performance of authorized duties, except as required by law or with the prior written consent of the Organization. This obligation survives termination of the delegation for a period of three years.

Acknowledgement of confidentiality obligation:

Representations, Warranties and Controls

The Requestor represents that the information provided in this form is true and accurate. The Organization reserves the right to impose additional controls, require countersignatures, or revoke authority if it determines that such action is necessary to protect its interests.

Governing Law

This delegation and any dispute arising out of or related to it shall be governed by and construed in accordance with the laws of the State of without regard to conflict-of-law principles.

Entire Agreement

This Signatory Request Form, together with any attached exhibits or written approvals incorporated by reference, constitutes the entire agreement between the parties concerning the delegation of signatory authority and supersedes all prior communications, representations, or agreements on that subject.

Approvals and Internal Routing

Internal reference or policy number:

Certification

By submitting this form and upon execution below, the signatory and the Organization each certify that (a) they have authority to enter into this delegation, (b) they will comply with applicable laws and internal policies, and (c) they understand the limits and responsibilities of the delegated authority.

Requestor acknowledges that misuse of delegated authority may result in disciplinary action, monetary liability, and revocation of privileges.

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