EXHIBIT E
Verizon Wireless - Georgia Technology Authority
Contract GTA-000187-010
Government Liability Authorization Form
Verizon Wireless requires that an authorized individual within your Agency approve the delegation or removal of an Authorized Contact on your account in writing using this form. An Authorized Contact is defined as an individual who is designated and granted authority to act on behalf of the Agency for any and all matters contemplated by the parties’ to Agency Agreement to include access to the account, ability to purchase equipment, add lines of service, cancel service, and make changes to the account that financially bind the Agency (“government subscriber lines”).
Government Subscriber lines of service are billed under the “Agency Name” and “Agency Federal Tax ID”. At the request of the Authorized contact, monthly billing for government subscriber lines of service can be sent to the Agency address or to an employee home address. By signing this form you have certified that you are authorized by the Agency and have the authority to financially bind the Agency. Whether payment is made directly by the Agency or by an employee, you have agreed that your Agency will accept legal liability for payment.
The following
(Print your Agency Name and Federal Tax ID)
employee(s) are authorized to access the account, purchase equipment, add lines of service, cancel service, make changes to the account and to sign a Verizon Wireless customer service order for corporately billed lines of cellular and paging service. In addition I am establishing the following _________________ (Numeric Pass code) on the account to help safeguard my account information.
Signature: ____________________________________________
(Authorized Signer)
Title: ________________________________________________ Date: _______________________
Request for Authorization Contact
List below the Agency employee(s) that you are requesting to be added or removed as Authorized Contacts for __________________________________________________________________________________________ (Agency Name)
Add – Authorized Contacts
|Name Printed: | | |Name Printed: | |
|Signature: | | |Signature: | |
|Officer/Title: | | |Officer/Title: | |
|Phone: | | |Phone: | |
Delete – Authorized Contacts
|Name Printed: | | |Name Printed: | |
|Signature: | | |Signature: | |
|Officer/Title: | | |Officer/Title: | |
|Phone: | | |Phone: | |
Sales Rep: _______________________ Location: _________________ Manager:_____________________
Waiver for Account Pass code
To help safeguard your account information, Verizon Wireless has introduced a process encouraging all accounts to establish a numeric pass code on their account. If you do not wish establish a pass code on your account, you assume the risk that an authorized person may access your account records, purchase equipment, add lines of service, cancel service, and make changes to the account that financially bind your Agency. By waiving the right to pass code protection, you are releasing Verizon Wireless from financial liability and liability for breaches of account security and privacy.
Signature: ____________________________ Date: ___________________________
(Authorized Signer
................
................
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