Signature Delegation For Permit Applications Compliance Reports And Notice Responses
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1SIGNATURE DELEGATION
For Permit Applications, Compliance Reports and Notice Responses
I, (
) of
NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
(
(“Company”)
),
NAME OF COMPANY AS REGISTERED WITH SECRETARY OF STATE OF OHIO
located a
t (
appoint
)
FULL ADDRESS OF AUTHORIZED REPRESENTATIVE
(
), as the Company Agent (attorney-in-fact) to act or the
NAME OF AGENT
Company in any lawful way with respect to the following subject:
To discuss, sign, execute and deliver any and all documents, reports, forms and
similar items such as Permit Applications, Periodic Compliance Reports, Notice of
Violations Responses, Certifications and other MSD forms on behalf of
(
) in all matters involving, directly or
YOUR COMPANY'S LEGAL NAME
indirectly, the Metropolitan Sewer District of Greater Cincinnati with respect to
(
) premises located at
YOUR COMPANY'S LEGAL NAME
(
).
YOUR COMPANY'S FULL PREMISE ADDRESS WITH ZIP CODE
Choice of Law. THIS POWER OF ATTORNEY WILL BE GOVERNED BY THE
LAWS OF THE STATE OF OHIO WITHOUT REGARD FOR CONFLICTS OF
LAWS PRINCIPLES. IT IS INTENDED TO BE VALID IN ALL JURISDICTIONS
OF THE UNITED STATES OF AMERICA.
I am fully informed as to all the contents of this form and understand the full import
of this grant of powers to my Agent.
I agree that any third party who receives a copy of this document may act under it.
Revocation of the power of attorney is not effective as to a third party until the third
party learns of the revocation. I agree to indemnify the third party of any claims that
arise against the third party because of reliance on this power of attorney.
Signed this ___ _ day of (
).
,
YEAR
MONTH
(
).
YOUR COMPANY'S FULL LEGAL NAME
By:
______________________________
To:
______________________
NAME OF AGENT
Signature of Authorized Representative
Agent
______________________________
___________________________
Printed Name/Title Authorized Representative
Printed Name/Title Agent
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