Form US EPA Electronic US EPA Electronic US EPA Electronic Signature Agreement

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 authorized official on behalf of:
Electronic Signature Holder Company Information
Parent Company
Name:
Address:
City, State, Zip:
Province:
Country:
Phone Number:
E-mail Address:
Site Name:
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;
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(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) Understand that I will receive an e-mail in my CDX inbox with a link to my encrypted,
electronically signed copy of my submission;
(9) 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;
(10) 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;
(11) 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;
(13) Understand that the Immediate Supervisor or Witnessing Official who signs below may be
contacted by the EPA and asked to validate my employment at the company listed above;
(14) 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,
(15) 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: _____________________________
Official Title:
Date:

__________________________________

Notary Public: __________________________________
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VERIFICATION OF COMPANY AUTHORIZING OFFICIAL
I,

acknowledge that the individual named above works at/for
(name of supervisor)
and is authorized to submit documents and sign the IUR Certification

(name of company)
Statement on the company’s behalf.

Signature of Immediate Supervisor or Witnessing Official

Date

Official Title

Notary Public: __________________________________

PLEASE SEND THIS DOCUMENT AS SOON AS POSSIBLE TO:
By U.S. Postal Service:

By Hand Delivery or Courier:

IUR CDX Registration Coordinator (7407M)
IUR CDX Registration Coordinator
U.S. Environmental Protection Agency
U.S. EPA- OPPT/RDMB
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
202-564-8956; 202-564-2818

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AUTHORIZATION AND VERIFICATION OF SUPPORT
SUBMITTER
Authorized Official Signature
I am an authorizing official and an electronic signature holder in U.S. EPA’s CDX for the organization
listed below. I verify that the person identified as the electronic signature holder below is authorized to
submit only support IUR information (i.e., amendments or correspondence) on behalf of my organization.
CDX User ID:
Name of Authorized Official:
Parent Company Name:
Address:
City/Town:

County/Parish:

State/Province:

Zip/Postal Code:

Country:

Signature:

Date:

Electronic Signature Holder for Submission of Supporting 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 support IUR information on behalf of the
organization listed above.
CDX User ID:
Name of Electronic Signature
Holder:
Parent Company Name:
Address:
City/Town:
Zip/Postal Code:

County/Parish:

State/Province:

Country:

Site Name:
Address:
City/Town:

County/Parish:

State/Province:

Zip/Postal Code:

Country:

Signature:

Date:

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PLEASE SEND THIS DOCUMENT AS SOON AS POSSIBLE TO:
By U.S. Postal Service:

By Hand Delivery or Courier:

IUR CDX Registration Coordinator (7407M)
U.S. Environmental Protection Agency
Office of Pollution Prevention and Toxics
Ariel Rios Building
1200 Pennsylvania Ave, NW
Washington, DC 20460

IUR CDX Registration Coordinator
U.S. EPA- OPPT/RDMB
EPA East Building, Room 6428
1201 Constitution Ave, NW
Washington, DC 20004-3302
202-564-8956; 202-564-2818

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