authorized representatives

NOR'IH CAROLINA FEDERAL PROPERTY AGENCY 1311 MAIL SER VICE CENTER RALEIGH, N.C. 27699-1311 (919)814-5600

AUTHORIZED REPRESENTATIVES I.

LEGAL NAME & MAILING ADDRESS OF APPLICANT ORGANIZATION: Name ofDrganwztion Zip Code

Mailing Address (P.O. Boz #, Street, City & Sta:te) S1ree1 Address/Location (Ifdifferentfrom mailing address)

Co.rucy

II.

Telephone#

THE FOLLOWING REPRESENTATIVES ARE DESIGNATED TO: A. B.

Represent Donee Organization as its authorized agent; and · Acquire Federal surplus propeny on behalf of the Donec Organization; and

C.

Obligate necessary Donce Organization funds for this purpose; and

D.

Execute Distribution Documents binding the Donee Organization to the terms, conditions, reservations, and restrictions applying to Propc.ny obtained through lhe agency.

III.

___ NEW DESIGNATIONS

IV.

REPRESENTATIVES:

__ ADDmONAL DESIGNATIONS ONLY

(Deku aJJprewous 11lllhori.vllions)

(Add to previous authol'iz,:,tion)

Signature

Titlt

V.

CERl'.lFic.::ATION Signature ofAulhorizd Official

PC-FS-99