2017-11-14_REPORT - M1996073

• Permit No: M1996073
• IBM Index Class Name: Report
• Doc Date: 11/14/2017
• Doc Name: Annual Fee/Report/Map
• From: Sedgwick County
• To: DRMS
• Annual Report Year: 2017
• Email Name: JLE
• 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:
The foregoing instrument was acknowledged
before me this
(Name of permittee representative)
(seal)
My Commission expires:
) ss.
day of I by
(date) (month) (year)
as
of
(title)
(permittee)
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NOTARY PUBLIC