Form Agntauthwww - Authorization Of Agent printable pdf download

Alaska Commercial Fisheries Entry Commission

8800-109 Glacier Hwy., Juneau, Alaska 99801 (907) 789-6150

Authorization of Agent - Year 20____

Instructions:

The permit applicant must complete the top part of this form and have his or her signature notarized. The agent or representative must complete

the bottom part of the form. The original of this form must be mailed to the Entry Commission. If it is necessary to expedite the application process, the

applicant may complete the top part of the form then FAX it to the person who is being authorized to act as the agent. That person may bring the FAX'd

copy to the commission's office to obtain the permits. Authorization by telephone will be accepted only if the commission determines that there is good

cause for waiving the requirement for written authorization signed and dated by the applicant.

To be completed by applicant:

______________________________________________________________________

Applicant's Name (please print)

Social Security Number

______________________________________________________________________

Permanent Mailing Address

Date of Birth

______________________________________________________________________

City

State

Zip

Home Telephone Number

Read the definition of Alaska resident, then check the boxes that apply:

A resident of Alaska is one who, on the date of permit application or renewal, and throughout the 12-month period before that

date, (A) except for brief intervals, military service, attendance at an educational or training institution, or absence for good cause is,

and was, physically present in the state with the intent to remain in the state indefinitely and to make a home in the state; and (B)

neither claimed nor received benefits as a resident of another state, territory or country.

Alaska resident

Nonresident

U.S. citizen

Alien (Alien Reg. No. ______________)

If you checked Alaska resident, indicate how long you have lived in Alaska and provide the street address or physical location of

your current residence:

Yrs.

Mos.

____________________________

______________________________________________________________________________________________________________________

How long in Alaska?

Street address or physical location of residence

City

State

Zip

List the permits and/or vessel licenses which the agent is authorized to obtain for you:

__________________________________________________________________________________________________________________________________________________________

Indicate fisheries for permits and ADF&G numbers (or vessel names) for vessel licenses.

I authorize ________________________________________________________________

to act as my agent in obtaining the

permits and/or vessel licenses listed above. The agent is authorized to complete permit and vessel license application/renewal forms,

submit the required fees and pick up the license(s) for shipment to me per my instructions to him or her. I certify that all of the

information provided by me on this form is true and complete to the best of my knowledge.

______________________________________________________________________

Signature of Applicant

Notary Public or Alaska Postmaster

Subscribed and sworn to before me this ____________ day of _________________________, 20 ______, at ____________________________________________________

(city/state)

To be completed by agent or representative:

I certify that I spoke to the applicant on _______________________ and s/he verified that the information on this form is

true and correct and authorized me to obtain the designated permits and/or vessel licenses. I certify that all of the information provided

by me on the permit and/or vessel license forms is true and complete to the best of my knowledge.

______________________________________________________________________

Signature of Agent

Date

Form AGNTAUTHwww (Rev. 12/99)