Power of Attorney Form Instructions
| (1)
| Check the box that applies
|
| (2) |
Type Federal Tax ID for company or Social Security # for individual |
| (3) |
Name of company |
| (4) |
State of incorporation, if a corporation |
| (5) |
Type of organization if other than a corporation, i.e.,: sole proprietorship |
| (6) |
name under which business is operated if a partnership or sole proprietorship |
| (7) |
Place of residence if individual or sole proprietorship |
| (8) |
Business address of firm |
| (9) |
Signature of authorized officer |
| (10) |
Print name of authorized officer |
| (11) |
Title of person signing |
| (12) |
Date of signature |
| (13) |
Signature and address of one witness to signature of individual issuing power of attorney |
| (14) |
Print name of witness |