POWER OF ATTORNEY 
 
KNOW ALL PERSONS BY THESE PRESENTS: 
 
THAT, ________________________________, GA DOL Account No. ___________________, 
having its principal office at ______________________________________________, hereby 
appoints ____________________________ as its true and lawful agent with full authority to 
represent the said __________________________ before the Georgia Department of Labor, 
until further notice, in connection with all matters affecting State Unemployment Insurance 
Taxes including, without limitation, all claims, tax contributions and experience ratings. 
 
This Power of Attorney supersedes and revokes any prior power of attorney authorization from 
the named employer relating to the subject matter hereof.  The undersigned warrants that he or 
she is authorized to execute this Power of Attorney. 
 
IN WITNESS WHEREOF, the undersigned has duly executed and delivered this Power of 
Attorney on behalf of the named employer this _____ day of __________________ 20____. 
 
                                                     ___________________________________ 
                                                     Employer’s Name 
                                                                                            
                                      By: ___________________________________ 
                                                     Signature 
                                                                                            
                                                     ___________________________________ 
                                                     Print or Type Name 
                                                                                            
                                                     ___________________________________ 
                                                     Title 
 
It is respectfully requested that all forms pertaining to unemployment taxes be mailed to the new 
ADDRESS OF RECORD as indicated below.