ESA and Authorizat Electronic Signature Agreement (Submission of Supplement

U.S. Environmental Protection Agency

ELECTRONIC SIGNATURE AGREEMENT

In accepting the electronic signature credential issued by the U.S. Environmental Protection Agency (EPA) to sign electronic documents submitted to EPA’s Central Data Exchange (CDX), and as an employee of:

Electronic Signature Holder Company Information

Company Name:
Address:
City, State, Zip:
Province:
Country:
Phone Number:
E-mail Address:
Registrant’s Name:
CDX User Name:

I, ________________________________________ ,

(Name of Electronic Signature Holder)

(1) Agree to protect the electronic signature credential, consisting of my Central Data Exchange (CDX) user identification and password, from use by anyone except me. Specifically, I agree to maintain the secrecy of the password; I will not divulge or delegate my user name and password to any other individual; I will not store my password in an unprotected location; and I will not allow my password to be written into computer scripts to achieve automated login;

(2) Agree to contact the U.S. EPA CDX Help Desk at 1-888-890-1995 as soon as possible, but no later than 24 hours, after suspecting or determining that my user name and password have become lost, stolen or otherwise compromised;

(3) Understand that I will be informed through my registered electronic mail (e-mail) address whenever my user identification or password have been modified;

(4) Understand that CDX reports the last date my user identification and password were used immediately after successfully logging into CDX;

(5) Agree that I will review the contents of all electronic submissions prior to submission;

(6) Understand and agree that I will be held as legally bound, obligated, or responsible by my use of my electronic signature as I would be using my hand-written signature;

(7) Understand that whenever I electronically sign and submit an electronic document to the CDX, I will receive an e‑mail at my registered e‑mail address; This e-mail will inform me that a submission has been made to CDX from my user account and will contain instructions to view information regarding the submission, including my Copy of Record (CoR);

(8) Agree that if I receive an e‑mail notification for a submission that I do not believe that I submitted, I will notify the CDX Help Desk as soon as possible, but no later than 24 hours, after receipt;

(9) Agree to contact the CDX Help Desk if I do not receive an e‑mail notification within 5 business days for any electronically signed submission using my credentials;

(10) Agree to report, within 24 hours of discovery, any evidence of discrepancy between an electronic document I have signed and submitted and what the CDX has received from me by contacting the CDX Help Desk;

(11) Agree to notify the EPA if I cease to represent the regulated entity specified above as signatory of that organization’s electronic submissions by contacting the CDX Help Desk as soon as this change in relationship occurs and to sign a surrender certification at that time; and,

(12) Agree to retain a copy of this signed agreement as long as I continue to represent the regulated entity specified above as signatory of the company’s electronic submissions.

Name of electronic signature holder: _____________________________

Signature of electronic signature holder: _____________________________

Date: __________________________________

NOTARY PUBLIC:

VERIFICATION BY COMPANY AUTHORIZING OFFICIAL

PMN Supplemental Submissions

Authorized Official Information

I am an authorizing official and an electronic signature holder in U.S. EPA’s CDX for the organization listed below, and verify that the person identified as the electronic signature holder below is authorized to submit only supplemental PMN documents (i.e., all support documents except for a Letter of Support) on behalf of my organization.
Name of Authorized Official:
Company Name:
Address:
City, State, Zip:
Signature		Date

Electronic Signature Holder for Submission of Supplemental Information

I acknowledge by my signature below that the accuracy of the statements in all electronic submissions reflect my best prediction of the anticipated facts regarding the chemical substance(s) described therein. Any knowing and willful misrepresentation is subject to criminal penalty pursuant to 18USC 1001. I also acknowledge that I am authorized to submit only supplemental PMN documents (i.e., all support documents except for a Letter of Support) on behalf of the organization listed above.
Name of Electronic Signature Holder:
Company Name:
Address:
City, State, Zip:
Country:			Province:
Signature				Date

PLEASE SEND THIS DOCUMENT AS SOON AS POSSIBLE TO:

By U.S. Postal Service: By Hand Delivery or Courier:

PMN CDX Registration Coordinator (7407M) PMN CDX Registration Coordinator

U.S. Environmental Protection Agency U.S. EPA- OPPT/CBIC

Office of Pollution Prevention and Toxics EPA East Building, Room 6428

Ariel Rios Building 1201 Constitution Ave, NW

1200 Pennsylvania Ave, NW Washington, DC 20004-3302

Washington, DC 20460 202-564-8930; 202-564-8940