DWS-UI             UTAH DEPARTMENT OF WORKFORCE SERVICES
Form POA
Rev. 09/16                                         Unemployment Insurance
                                                   P.O. Box 45288
                                                   Salt Lake City, Utah   84145-0288
                                                   Fax (801) 526-9377

           POWER OF ATTORNEY / AUTHORIZATION OF AGENT FORM

KNOW ALL MEN BY THESE PRESENTS:

THAT THE UNDERSIGNED, 

a                                                  Federal Identification Number:
           ( corporation, partnership, individual )

State Identification Number:                                         State:

Having its principal office at: 

Does hereby constitute and appoint:
                                                                 ( Agent legal name )

its divisions and subsidiaries the true and lawful attorneys-in-fact of the undersigned, until further written notice, to
represent the undersigned before any and all government bodies, agencies or instrumentalities, in all matters
affecting unemployment insurance taxes including, without limitation, the following:

( Check and complete all applicable types )

           Unemployment tax matters
                   Agent Address

           Agent City, State and Zip

                   Agent Telephone

                                                   Check this box to send new correspondence to the above address.

           Unemployment claims matters (determinations, hearing notices, appeals, benefit
           charges)
                   Agent Address

           Agent City, State and Zip

                   Agent Telephone

                                                   Check this box to send new correspondence to the above address.

Each of said attorneys-in-fact shall have the power to act with or without the others and the power authority to
perform, in the name and on behalf of the undersigned, every act necessary to carry out the subject matter hereof
as fully as the undersigned could do.  The undersigned hereby ratifies and approves the acts of said
attorneys-in-fact.  The services to be performed shall specifically exclude any which now or in the future may be
deemed to be the practice of law.

This Authorization supersedes and revokes any prior power of attorney
authorization from the undersigned relating to the subject matter hereof, and is
valid from this date until rescinded by a letter or superseded.

IN WITNESS WHEREOF, the undersigned has duly executed and delivered this
Authorization this ___________ day of _______________________, 20___ . 

Notary seal (required)

                            Name of Company          ( type or print )

                      B y : 
                            Signature                  ( Authorized Officer )

                            Name and Title                 ( type or print )

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