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Agent Information

2-2-1 Name and Address
2-2-2 Daytime Telephone Number
2-2-3 FAX Number
2-2-4 Example Applicant Information

If applicable, provide sufficient agent information to allow Department staff to contact the agent by telephone, FAX, or mail. Include the following items:

2-2-1 Name and Address:

A. Provide the name and complete mailing address of the agent.

  1. If there are multiple agents, provide the name and address of the agent serving as the contact agent on the application form and the names and addresses of the additional agents and their areas of responsibility on a separate page.

2-2-2 Daytime Telephone Number:

A. Provide the agent's daytime telephone number. Include the area code and applicable extension.

2-2-3 FAX Number - If Available:

A. Provide the agent's FAX number. Include the area code and applicable extension.

2-2-4 Example Agent Information:

A. Single Agent - Agent shown on the application form

  1. Application Form

    Site Planning Associates, Ltd.
    Mr. Paul A. Johnson, PE
    Grand View Office Park
    Suite 745
    8935 Louis Boulevard
    Indianapolis, Indiana 46204

    Phone (317) 555-1212
    FAX (317) 555-1212

B. Multiple Agents - Contact agent shown on the application form with the additional agent(s) and responsibilities shown on a separate page

  1. Application Form

    Motley, Smith and Anderson
    Attorneys At Law
    Mr. Michael A. Smith (contact agent)
    35th Floor, Suite 3529
    Universal Bank Tower
    8943 East Market Street
    Evansville, Indiana 47708

    Phone (812) 555-1212
    FAX (812) 555-1212
     
  2. Separate Page
    Additional Agents:
    Agent Responsibility
    Site Engineering Associates, Inc
    Ms. Elizabeth A. Baxter, PE,
    5629 West 87th Place
    Vincennes, Indiana 47591

    Phone (812) 555-1212
    FAX (812) 555-1212    		 Overall development plan
    Mr. James R. Purcell
    358 North Walnut Street
    Newburgh, Indiana 47629

     

    Phone (812) 555-1212
    FAX (812) 555-1212    		 Hydrology and hydraulics
    Environmental Associates, Ltd.
    Ms. Jennifer E. Richards
    147 State Road 41
    Evansville, Indiana 47591

     

    Phone (812) 555-1212
    FAX (812) 555-1212    		 Environmental assessment