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: HYPERLINK "http://www.txsmartbuy.com/" INCLUDEPICTURE "https://comptroller.texas.gov/purchasing/images/TXsmartBuyMembersLogo.png" \* MERGEFORMATINET
Texas SmartBuy Membership Agent of Record Name Change Form
Account number: _____________
Entity name: ________________________________________________________
The Agent(s) of Record for the above-mentioned entity are:
Primary Agents Name: ______________________________________________
(This person will receive all correspondence from CPA)
Primary Agents Title: ______________________________________________
Signature: ______________________________________________
E-mail: ______________________________________________
Secondary Agents Name: _____________________________________________
(This person will receive all correspondence from CPA)
Secondary Agents 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
Agents Name and Title: ____________________________________________
Signature: ____________________________________________
Agents Name and Title: ____________________________________________
Signature: ____________________________________________
Agents Name and Title: ____________________________________________
Signature: ____________________________________________
If you have questions about this form, please call 512-463-3368. Please submit the completed form by email: HYPERLINK "mailto:members@cpa.texas.gov" members@cpa.texas.gov or by fax: 512-936-2667
INCLUDEPICTURE "https://comptroller.texas.gov/purchasing/images/TXsmartBuyMembersLogo.png" \* MERGEFORMATINET
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