Field 19: Authorized Representative Information

Prefix 

Enter the prefix (e.g. Mr., Ms., Rev., Dr.) for Authorized Representative. 

First Name 

Enter the first (given) name of the Authorized Representative.  This field is required. 

Middle Name 

Enter the middle name of the Authorized Representative. 

Last Name 

Enter the last name of the Authorized Representative.  This field is required. 

Suffix 

Enter the suffix (e.g., Jr., Sr., Ph.D.) of the Authorized Representative. 

Position/Title 

Enter the position or title of the Authorized Representative.  This field is required. 

Organization 

Enter the name of the organization for the Authorized Representative.  This field is required.  

Department 

Enter the name of the primary organizational department, service, laboratory, or equivalent level within the organization of the Authorized Representative. 

Division 

Enter the name of the primary organizational division, office, or major subdivision of the Authorized Representative. 

Street 1 

Enter the first line of the street address for the Authorized Representative.  This field is required. 

Street 2 

Enter the second line of the street address for the Authorized Representative if additional line is needed, for example suite number or building number.  This field is optional. 

City 

Enter the city for address of the Authorized Representative.  This field is required. 

County/Parish 

Enter the county or parish for the address of the Authorized Representative. 

State 

Enter the state where the Authorized Representative is located.  This field is required if the applicant is located in the United States. 

Province 

Enter the province for the Authorized Representative. 

Country 

Select the country for the address of the Authorized Representative.  For SBIR/STTR applications, the small business concern must be located in the United States. 

Zip Code 

Enter the nine-digit postal code of the Authorized Representative.  This field is required if the applicant is located in the United States.  If a province is selected, this field is optional. 

Phone Number 

Enter the daytime phone number of the Authorized Representative.  This field is required.  

Fax Number  

Enter the fax number of the Authorized Representative. 

Email 

Enter the email address for the Authorized Representative.  Provide only one email address.  This field is required.   

Signature of Authorized Representative 

It is the organization’s responsibility to ensure that only properly authorized individuals sign in this capacity and/or submits the application to Grants.gov.  If this application is submitted through Grants.gov, leave blank.  If a hard copy is submitted, the AOR must sign this block. 

Date Signed 

If this application is submitted through Grants.gov, the system will generate this date.  If submitting a hard copy, enter the date the AOR signed the application.