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237 Coliseum Drive ● Macon, Georgia 31217 ● (478) 207-2440 www.sos.ga.gov State Licensing Board for State Licensing Board for Residential and General Contractors The Authorized Permit Agent form may be used by a licensed contractor to designate an individual to obtain permit(s) on his/her behalf for a project(s). The contractor should submit an Authorized Permit Agent Form for each project that he/she designates an individual to pull permits for. The form is to be given to the permit office in the city or county in which the project is located. Do not send a copy of this form to the Board office unless you are requested to do so. ---PAGE BREAK--- 237 Coliseum Drive ● Macon, Georgia 31217 ● (478) 207-2440 www.sos.ga.gov State Licensing Board for State Licensing Board for Residential and General Contractors Authorized Permit Agent Form License verification by permitting office should be completed by visiting sos.ga.gov/plb/ Licensed Contractor: _____Individual _____Qualifying Agent Name of licensed person *Please attach a copy of Individual license or Company License (Reflects company and qualifying agent license number) License number of individual or qualifying agent: Name of licensed company(if applicable) License number of company(if I, hereby designate Licensed Individual or Qualifying Agent to apply for and obtain the permit(s) for the *Please attach a copy of the authorized permit agent’s driver’s license. project at: Street address Apartment or Suite Number City Zip Code I, the undersigned, being the contractor as either an individual or a qualifying agent, do hereby affirm and swear, under oath, that all information on this form and on accompanying documents are true and correct. Signature of individual or qualifying agent State of County of Subscribed and sworn to before me this day of Signature of Notary (Seal)