Employment Security Commission Of North Carolina Power Of Attorney And Declaration Of Representative (Page 2 of 2) in pdf

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

REVISED 2-20-96

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

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

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