Shown is the Designation for Certifying Officer Form as identified in the text. The form has seven sections. The first section has areas to fill out listing the ALC, new or renewal designation, and certification functions authorized. The second section lists the name, address, phone number, and effective date of the Designee. The third section has four blocks for the Designee to sign their signature in each of the blocks. The fourth section is for the Designator to sign their signature and list their title and organization. The fifth section has a box for the Designator to check revoking the Designee's authorization. The sixth section lists the Designator's return address and phone number. The seventh section lists the regional Financial Centers (RFC) with a box next to each to be checked off indicating the RFC the Certifying Officer will certify to.