Limited Power Of Attorney Template
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1
2LIMITED POWER OF ATTORNEY
I hereby designate and appoint the holder of this Certificate as my true and
Name ____________________________________________
lawful attorney-in-face for the limited purpose of entering a plea and
Address __________________________________________
securing appropriate legal representation of my interest concerning Citation
No. ________________________
_________________________________________________
My attorney-in-fact is to exercise his/her best professional judgement in
_________________________________________________
rendering this assistance, and I understand and agree to be responsible for
payment of any fines and/or court costs assessed by the court.
SS# _____________________________________________
In addition, I hereby give authorization to TVC Pro-Driver, Inc. to perform a
CSA/DATAQ Challenge on my behalf for this matter, if applicable.
Signature ________________________________________
If necessary, I would be willing to (check all that apply):
Date ____________________________________________
Attend trial (a future court date)
Telephone # (_______) _____________________________
Allow attorney to enter into a plea agreement (negotiate for a
reduction, amendment or dismissal of charge)
Dispatch # (_______) _______________________________
Attend defensive driving school. If yes, have you been to
defensive driving school in past 18 months? Y or N
Driver’s License State/No. ___________________________
If yes, when and where? ___________________________
A fax or photocopy of this power of attorney is just as binding as the original when in the possession of an assigned agent or attorney.
LIMITED POWER OF ATTORNEY
I hereby designate and appoint the holder of this Certificate as my true and
Name ____________________________________________
lawful attorney-in-face for the limited purpose of entering a plea and
Address __________________________________________
securing appropriate legal representation of my interest concerning Citation
No. ________________________
_________________________________________________
My attorney-in-fact is to exercise his/her best professional judgement in
_________________________________________________
rendering this assistance, and I understand and agree to be responsible for
payment of any fines and/or court costs assessed by the court.
SS# _____________________________________________
In addition, I hereby give authorization to TVC Pro-Driver, Inc. to perform a
CSA/DATAQ Challenge on my behalf for this matter, if applicable.
Signature ________________________________________
If necessary, I would be willing to (check all that apply):
Date ____________________________________________
Attend trial (a future court date)
Telephone # (_______) _____________________________
Allow attorney to enter into a plea agreement (negotiate for a
reduction, amendment or dismissal of charge)
Dispatch # (_______) _______________________________
Attend defensive driving school. If yes, have you been to
defensive driving school in past 18 months? Y or N
Driver’s License State/No. ___________________________
If yes, when and where? ___________________________
A fax or photocopy of this power of attorney is just as binding as the original when in the possession of an assigned agent or attorney.
LIMITED POWER OF ATTORNEY
I hereby designate and appoint the holder of this Certificate as my true and
Name ____________________________________________
lawful attorney-in-face for the limited purpose of entering a plea and
Address __________________________________________
securing appropriate legal representation of my interest concerning Citation
No. ________________________
_________________________________________________
My attorney-in-fact is to exercise his/her best professional judgement in
_________________________________________________
rendering this assistance, and I understand and agree to be responsible for
payment of any fines and/or court costs assessed by the court.
SS# _____________________________________________
In addition, I hereby give authorization to TVC Pro-Driver, Inc. to perform a
CSA/DATAQ Challenge on my behalf for this matter, if applicable.
Signature ________________________________________
If necessary, I would be willing to (check all that apply):
Date ____________________________________________
Attend trial (a future court date)
Telephone # (_______) _____________________________
Allow attorney to enter into a plea agreement (negotiate for a
reduction, amendment or dismissal of charge)
Dispatch # (_______) _______________________________
Attend defensive driving school. If yes, have you been to
defensive driving school in past 18 months? Y or N
Driver’s License State/No. ___________________________
If yes, when and where? ___________________________
A fax or photocopy of this power of attorney is just as binding as the original when in the possession of an assigned agent or attorney.
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