Power Of Attorney And Declaration Of Representative Form 2012 (Page 2 of 2) in pdf

Power Of Attorney And Declaration Of Representative Form 2012 Page 2

REVISED 01/2012

8. The undersigned employer acknowledges that the representative is not authorized by

this document to represent the employer in any hearings conducted by the Division of

Employment Security or to enter any appeals from any decisions of the Division of

Employment Security whether such decisions are rendered by Adjudicators, Appeals

Referees, the Assistant Secretary, or any other authorized employee of the Division of

Employment Security.

To comply with the requirements of N.C.G.S. 96-17(b) , a

separate form Notice of Attorney Supervision must be completed in order for the

representative to appear at hearings or to enter notice of appeal for the employer; and

9. The representative’s address (is)(is not) to be the address of record in matters

regarding contributions (tax) and benefit claims; (is) (is not) to be the special claims

address in matters regarding benefits (claims only).

This Power of Attorney and Declaration of Representative shall become effective on the

______ day of _________________________, ________, and shall remain in effect until

revoked by the employer, the representative, or the Division of Employment Security.

(SEAL)

AUTHORIZING SIGNATURE (must be the proprietor, a general

TITLE

partner or duly elected corporate officer)

TYPED OR PRINTED NAME

SUBSCRIBED AND SWORN to before me on this _____ day of ________________, ______.

NOTARY PUBLIC

(Notary Seal)

My Commission expires __________________________, _________.

REPRESENTATIVE NAME

ADDRESS

CITY, STATE, ZIP

REPRESENTATIVE SIGNATURE

TYPED OF PRINTED NAME

TITLE

Power Of Attorney And Declaration Of Representative Form 2012 Page 2