Official Use Only
Application for EFAST Electronic Signature
and Codes for EFAST Transmitters and
OMB No. 1210-0117
For Paperwork Reduction Act Notices, see instructions.
Form EFAST-1 (Rev. 03/07)
M M / D D / Y Y Y Y
Signature of applicant
Name (last, first, and initial) and title of applicant
Type of Application
Each applicant must check all appropriate boxes in Part I, complete Parts II and III, and sign the Applicant Agreement.
A This is an application for an EFAST electronic signature.
B This is an application for EFAST codes for the purpose of being an EFAST Transmitter.
C This is an application for EFAST codes for the purpose of being an EFAST Software Developer.
D This application is being submitted to update information for an EFAST Transmitter or an EFAST Software Developer.
Please read the instructions before completing this application.
Department of Labor
If this application results in the issuance of an electronic signature, I understand and agree that the electronic signature is not transferable
and that the inclusion of such electronic signature in a Form 5500 return/report or Form 5500-EZ return filed in electronic form shall have the
same legal force and effect as my hand written signature. If I am not the Transmitter, I also agree that my electronic signature on a Form 5500
or Form 5500-EZ constitutes consent for EFAST personnel to send my Transmitter an acknowledgment of receipt of transmission and to
communicate with my Transmitter about the success or failure of the transmission and the specific reason(s) for any failure(s).
If this is an application to be an EFAST Software Developer or EFAST Transmitter, I declare that I am authorized to make and sign this
statement on behalf of the applicant. The applicant agrees that it and its employees will comply with all provisions of the EFAST procedures
for the electronic/magnetic/optica