Support Authorization Restrictions Form

Exceptional and Authorized Support NOTICE:

If BERACHA works with your organization, all of your employees and/or volunteers are authorized to seek Tier 1, Tier 2 and Tier 3 Service and Support by default. If there are select groups of employees and/or volunteers you wish to restrict from seeking service, your organization’s management is required to complete this authorization form below to make this declaration. If you declare an authorized subset of employees and /or volunteers who are permitted to request service, we will refuse service to those who contact us but who are without authorization.

(Please enter both first and last name, and separate by commas - such as John Doolittle, Jane Fox, Perry Mason, etc.)
(Please enter both first and last name, and separate by commas - such as John Doolittle, Jane Fox, Perry Mason, etc.)
(Please enter both first and last name, and separate by commas - such as John Doolittle, Jane Fox, Perry Mason, etc.)
(In addition to the names listed above) Select Yes or No
(unless I preauthorize additional employees and/or volunteers) Select Yes - or No if you do/do not understand this.
(by permitting authorized support) Select Yes - or No if you do/do not understand this.