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(Please Type Or Print The Requested Information) <br />(person's name) <br />(title) <br />-----of -- - - -- ---(name of company,-association,-organization etc:) am ~ ~~-' <br />authorized to delegate <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 Board in <br />this matter. ~ . <br />SIGNED AND DATED TffiS DAY OF <br />Authorized Signature (must be signed in blue ink) <br />If corporation attest (seal) <br />Title: <br />State of ) <br />ss <br />County of ) <br />The foregoing instrument was aclmowledged before me this day of , <br />by <br />as <br />of <br />Notary Public <br />My commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />A:lblkdalprtywvewp <br />