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