GSC Co-Op Agent of Record Name Change Form
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Texas SmartBuy Membership Agent of Record Name Change Form
Account number: _____________
Entity name: ________________________________________________________
The Agent(s) of Record for the above-mentioned entity are:
1) Primary Agent’s Name: ______________________________________________
(This person will receive all correspondence from CPA)
Primary Agent’s Title: ______________________________________________
Signature: ______________________________________________
E-mail: ______________________________________________
2) Secondary Agent’s Name: _____________________________________________
(This person will receive all correspondence from CPA)
Secondary Agent’s Title: _____________________________________________
Signature: _____________________________________________
E-mail: _____________________________________________
❑ Check here if additional Agents of Record are enclosed
Approval Signature is REQUIRED and must be one of the following:
✓ Previously approved Agent of Record
✓ Current Agent of Record
✓ Chairman of the Governing Board
Requestor Name and Title: _______________________________________________
Requestor Signature: _______________________________________________
Date: _______________________________________________
Additional Contacts for Reference
* The names below will go on file for records only
3) Agent’s Name and Title: ____________________________________________
Signature: ____________________________________________
4) Agent’s Name and Title: ____________________________________________
Signature: ____________________________________________
5) Agent’s Name and Title: ____________________________________________
Signature: ____________________________________________
If you have questions about this form, please call 512-463-3368. Please submit the completed form by email: members@cpa. or by fax: 512-936-2667
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