NOTICE OF ATTORNEY SUPERVISION 
                   PURSUANT TO N.C.G.S. 96-17 (b) 
 
To: NC Department of Commerce 
    Division of Employment Security 
    ATTN:   Legal 
    Post Office Box 25903 
    Raleigh, North Carolina  27611 
 
From:                                     
    Typed or Printed Name of Attorney 
    Licensed to Practice in the State of 
             North Carolina  
 
    North Carolina State Bar No. 
 
    Address  
                                          
    TO THE CHIEF COUNSEL OF THE DIVISION OF EMPLOYMENT SECURITY: 
                                           
    The undersigned attorney licensed to practice law in the State of North Carolina, said 
license being in good standing, certifies that the following individual(s) is/are working under 
his/her supervision pursuant to the requirements of N.C.G.S. 96-17(b) 
 
    This the        day of                 ,      . 
 
                                           __________________________________ 
                                           Signed 
                                                                      REVISED 01/2012