Power of Attorney Registration Application

Business Form - Application

What type of document do you want to purchase?

Billing Information

First Name

Last Name

Phone/Mobile

Confirmation Receipt Email Address

Card Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Debit or Credit Card Number

Expiration Date

CVV Code

What state will this document be used?

What date do you want this Power of Attorney become active?

Name of person who is granting the Power of Attorney?

First Name

Last Name

Phone/Mobile

Grantor Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Who do you wish to act on your behalf?

The person appointed by the principal, and given authority to act for the principal, is called the Attorney-in-fact. Please list the details.

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Do you wish to name an alternate Attorney-in-fact if the primary is not able or unwilling?

Alternate Attorney-in-fact Details

First Name

Last Name

Phone/Mobile

Attorney-in-fact | Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Attorney-in-fact Powers (General Authority)

The power to act on your behalf will be granted in these specific areas:

Restrictions - Do you wish to put restrictions on your Attorney-in-fact?

Please complete only if you wish to restrict these options.

Customize Restriction: Describe the restriction using complete sentences:

About Attorney-in-fact compensation

Depending on the kind of relationship you have with the person who will be acting as your Attorney-in-fact, you will have to consider how they should be paid for their services.

You can stipulate in your document that your Attorney-in-fact will not receive any payment except the reimbursement of out-of-pocket expenses as this is the starting point for compensation, or you can agree to pay your Attorney-in-fact a specified amount. If you prefer, you can authorize your Attorney-in-fact to pay him or herself a reasonable amount for acting for you.

Out-of-pocket expenses are expenses that your Attorney-in-fact pays out of his or her own pocket while performing tasks related to this Power of Attorney.

These expenses would include gasoline, parking, administration fees, etc.

How will my Attorney-in-fact be compensated financially?

Describe how your Attorney-in-fact will be compensated: Only complete if you need to specify

Select any options you wish to apply to your Power of Attorney:

Do you wish to specify when this Power of Attorney will end?

Please select the date if you want to specify an end date otherwise leave it blank to non expiring.

Where will you sign the document at? List the city and state only

Will you sign the document in front of a notary public?

Authorized Signature

Certified Mobile Notary Service

(405) 568-7539

hr@certifiedmobilenotaryservice.com