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Power Of Attorney And Declaration Of Representative - Employment Security Commission Of North Carolina Page 2

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

document to represent the employer in any hearings conducted by the Employment Security

Commission of North Carolina or to enter any appeals from any decisions of the

Employment Security Commission of North Carolina whether such decisions are rendered

by Adjudicators, Appeals Referees, Deputy Commissioners, Commissioners, the Chairman,

or any other authorized employee of the Employment Security Commission of North

Carolina. 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 Employment Security Commission of North Carolina.

_______________________________(SEAL)

_____________________________

AUTHORIZING SIGNATURE (must be the proprietor, a general partner,

TITLE

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 OR PRINTED NAME

TITLE

Power Of Attorney And Declaration Of Representative - Employment Security Commission Of North Carolina Page 2