OTC PR WIRE Ticker Authorization Form

I authorize OTC PR WIRE, LLC and OTC PR WIRE Press Partners to issue a company wire press release on our behalf and using our public ticker symbol. I have authority to legally bind the company and to provide this authorization*. This form may be digitally signed or signed by hand

Authorization form MUST be signed by a C-level of below public company and MUST include a valid company email, title and contact details from the company domain prior to OTC PR WIRE providing Wire Press Releases. NO Yahoo, Hotmail, Gmail or personal email will accepted; nor will ADMIN@ IR@, INFO@ or PR@ via company email.

Company Name:*

Company Address:*

Ticker Symbol if available:

Full Name:*

Title:*

Email :*

example@example.com

Phone Number:*

Signature*

Date:*

Date

I further authorize the individuals listed below to request and approve content on behalf of the above public company:

	Full Name	E-mail address	Phone Number
Authorized User
Aurhorized User
Authorized User

* Permission hereby continually authorizes OTC PR WIRE, LLC & Wire Press Partners to utilize company’s ticker symbol and disseminate press releases once approved by company until permission granted from this form as of its efective date is removed via written correspondence via email cs@otcprwire.com

State:

Postal Code:

Country:

Email

example@example.com

Phone Number

Area CodePhone Number

Address:

KYC INFORMATION (REQUIRED)

Category*

Individual/Proprietary firmCompanyTrusts/FoundationsPartnership firm

Name of the Individual including alias/ Proprietary Firm/Company/Trusts/Foundations/Partnership Firm (name of all partners)*

Permanent or Registered address of the Above listed Individual(s) or Entity*

Phone Number*

E-mail address*

example@example.com

Website*

Name of Authorized signatory. *

example@example.com

Please provide recent ID Copy (Passport, Driver License)

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I/We hereby declare that the particulars given herein above are true, correct and complete to the best of my/our knowledge and belief, the documents submitted in support of this Form KYC are genuine and obtained legally from the respective issuing authority. In case of any change in any of the aforementioned particulars, I/we undertake to notify you immediately in writing failing which the above particulars may be relied. I/we hereby authorize you to submit the above particulars to the customs and other regulatory authorities on my/our behalf as may be required.

Signed at: (city, state)*

*

Signature*