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<br />AUTHORI~:ATION TO REPRESENT A PARTY <br />(Please Tvp~e Or Print The Requested Information) <br />SIGNATUBES MUST BE IN BLUE INK <br />I <br />(person's name) <br />of <br />authorized to delegate <br />(title) <br />(name of company, association, organization, etc.) am <br />,a <br />(person's name) (consultant, etc.) <br />to represent (name of person, company, association, organization, <br />etc.) at the Pre-hearing Conference and/or Hearing before the Mined Land Reclamation Boaid in <br />this matter. <br />SIGNED AND DATED TI)(IS DAY OF <br />If corporation attest (seat) <br />Authorized Signature (must be signed in blue ink) <br />Title: . <br />State of ) <br />ss <br />County of ) <br />The foregoing instrument was aclmowledged before me this day of , <br />by as of <br />Notary Public <br />My commission expires: _ <br />SIGNATURES MUST BE IN BLUE INK <br />A:~blkda~pttywvawp <br />