2017-06-21_REPORT - M1983084

• Permit No: M1983084
• IBM Index Class Name: REPORT
• Doc Date: 6/21/2017
• Doc Name: Returned Mail
• From: USPS
• To: DRMS
• Email Name: MAC
• Media Type: D
• Archive: No

Agreement to Conduct Permitting by Electronic Means
Name of permittee representative desiring to
opt in to ePermit:
Title:
Name of permittee:
Signature:
ePermitting Administrator(if different from
representative signing agreement)
Email Address for ePermit Account:
Notarized Affidavit of Signature
STATE OF: )
COUNTY OF: ) ss.
The foregoing instrument was acknowledged
before me this day of by
(date) (month) (year)
as
(Name of permittee representative) (title)
of
(permittee)
NOTARY PUBLIC
(seal)
My Commission expires:
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