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Es-905 - Power Of Attorney/authorization Of Agent - State Of New Mexico Department Of Workforce Solutions

STATE OF NEW MEXICO

DEPARTMENT OF WORKFORCE SOLUTIONS

WORKFORCE TRANSITION SERVICES

POWER OF ATTORNEY/AUTHORIZATION OF AGENT

NOTICE: THIS IS AN IMPORTANT DOCUMENT. THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. IF YOU HAVE

ANY QUESTIONS ABOUT THESE POWERS, YOU SHOULD ASK A LAWYER TO EXPLAIN THEM TO YOU. THIS FORM DOES NOT PROHIBIT THE

USE OF ANY OTHER FORM. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.

Employer Account Number________

Legal Employer Name

Trade Name - DBA (if applicable)

Federal ID Number

Official Mailing Address

Phone Number

City, State, Zip Code

DOES HEREBY APPOINT AS THE DULY AUTHORIZED ATTORNEY-IN-FACT/AGENT:

Name

_____________________________

Address

Phone Number

City, State, Zip Code

THIS AUTHORIZATION ALLOWS THE ATTORNEY-IN-FACT/AGENT TO ACT IN THE EMPLOYER'S NAME, RECEIVE

CONFIDENTIAL INFORMATION, AND PERFORM THE UNEMPLOYMENT COMPENSATION FUNCTION(S) CHECKED BELOW.

CHANGE THE OFFICIAL MAILING ADDRESS TO:

_____________________________________________________________________________________________

Check All That Apply:

All Unemployment Matters

All Claims Matters

All Tax Matters

Appeals

THIS AUTHORIZATION MUST BE SIGNED BY A SOLE PROPRIETOR, PARTNER, OR CORPORATE OFFICER, AND CONTAIN

COMPLETE INFORMATION WHICH IS VERIFIABLE WITH THE DIVISION'S RECORDS.

IT MUST BE NOTARIZED, AND

SUPERSEDES AND REVOKES ANY PRIOR AUTHORIZATION RELATING TO THE SUBJECT MATTER(S) CHECKED ABOVE,

UNLESS THE EMPLOYER NOTIFIES THE DIVISION THAT THERE IS MORE THAN ONE ATTORNEY-IN-FACT. IT SHALL REMAIN

IN EFFECT UNTIL WRITTEN NOTICE OF CANCELLATION OR A SUBSEQUENT AUTHORIZATION IS RECEIVED BY THE

DIVISION OF UNEMPLOYMENT COMPENSATION. IT SHALL NOT BE AFFECTED BY LAPSE OF TIME. THE PRINCIPAL AGREES

THAT ANY THIRD PARTY WHO RECEIVES A COPY OF THIS DOCUMENT MAY ACT UNDER IT.

_________________________________________

______________________________________________

PRINT PRINCIPAL'S NAME

PRINCIPAL'S SIGNATURE

STATE OF NEW MEXICO

)

) ss.

COUNTY OF _________________ )

SUBSCRIBED and sworn to before me this _______ day of ____________________,__________.

(seal)

_________________________________

NOTARY PUBLIC

My Commission Expires:

ES-905 Rev.6/08

P O BOX 2281, ALBUQUERQUE, NM 87103 - (505) 841-2000

Es-905 - Power Of Attorney/authorization Of Agent - State Of New Mexico Department Of Workforce Solutions

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