Free Microsoft Word - LB-0927NewAddress.DOC - Tennessee


File Size: 18.2 kB
Pages: 1
Date: December 28, 2007
File Format: PDF
State: Tennessee
Category: Workers Compensation
Author: CC30218
Word Count: 138 Words, 972 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.tn.us/labor-wfd/Employers/forms/LB-0927.pdf

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State of Tennessee Department of Labor and Workforce Development Employer Services Unit 220 French Landing Drive Nashville, Tennessee 37243

Power of Attorney
This is to certify: Located at: City: Phone: is authorized to represent (employer) Applied For Employer's Federal Employer Identification Number: State: Fax: Zip:

Applied For

Employer's Tennessee Employer Account Number:

before the Tennessee Department of Labor and Workforce Development for the item(s) checked below:

for completing and filing quarterly Premium and Wage Reports.

for benefit charge management.

This authorization supersedes all prior Powers of Attorney. Employer Name: Trade Name: Mailing Address:

Required: Authorized Employer Signature: Print Name of Signer:
Return to:

Date: _____________________ Title:
Phone: FAX: 615-741-2486 615-741-7214
RDA/NA

Tennessee Department of Labor and Workforce Development Employer Services Unit 220 French Landing Drive Nashville, TN 37243

LB-0927