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Georgia Employee Leasing Company's Power of Attorney Form

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Georgia Employee Leasing Company's Power of Attorney Form Page 2
Georgia Employee Leasing Company
This Power of Attorney, being coupled with an interest in the Employment Security Law, shall be irrevocable
by
as long as said employer has made the election described above. This Power of Attorney shall remain in
force as long as any obligations remain due thereunder and until there shall be revocation of this Power
by both and the Attorney in Fact and
written proof thereof to obligor Bank. The obligor Bank shall honor this Power of Attorney but shall be under no obligation for the
proper application of funds that are forwarded to the Georgia Department of Labor.
IN WITNESS WHEREOF, , has hereunto
set its offi cial hand and seal this day of , 20 .
(Employer)
ATTEST:
BY
(Person who is authorized to sign this Power of Attorney must attach
proper authorization to sign for the named employer.)
NOTICE OF RECEIPT OF SECURITY BY DEPOSITORY BANK:
Receipt of securities described herein is hereby acknowledged and such security will not be released unless written authority
is received from the Attorney in Fact.
(Date)
(Signature of Bank Offi cial) (Title)
If you have any questions with respect to this form, call (404) 232-3310.
(Signature of Offi cer)
(employer)
(employer)
(employer)
Georgia Employee Leasing Company's Power of Attorney Form
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