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POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
THAT Employer Registration Number __ having its principal office
at does hereby appoint
its true and lawful attorney in fact with full power and authority to represent the said before the NEW JERSEY
DIVISION OF EMPLOYER ACCOUNTS until further notice, to wit: All matters affecting quarterly contributions reports, experience rating and
claims for benefits.
THIS AUTHORIZATION CANCELS AND SUPERSEDES ALL PRIOR POWERS OF ATTORNEY.
IN WITNESS WHEREOF, the said has caused this instrument to be signed, sealed and acknowledged by its duly
authorized qualified officer this day of
,
(Name of Company)
CORPORATE SEAL By
(Signature of Authorized Officer)
(Name and Title of Authorized Officer)
AFFIDAVIT:
I being duly sworn depose and say that I hold the office of , in the I Employer
Registration Number having its principal office at and am fully authorized on behalf of such
company to grant the powers stated in said Power of Attorney to as the true and lawful attorney in fact with power
and authority to represent before the NEW JERSEY DIVISION OF EMPLOYER ACCOUNTS without
first obtaining the direction and approval of the Board of Directors of
.
(Signature of Authorized Officer)
Be it known that on this day of I before me notary public for this State
of residing in the county of , duly commissioned and sworn and by law authorized to administer oaths and
affirmations, personally appeared and being sworn by me did depose and say that the contents in the foregoing
affidavit are true and correct.
Notary Public
(NOTARY SEAL) Notary Expiration:
ACCEPTANCE:
I being a duly qualified officer of hereby accept on behalf of the
said corporation the power herein described granted by
Signature :
Title:
Authorized Agent Reg No.: ___________________________________________
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