Form A-5 Corporate Resolution Authorizing Application {A-5}

Form A-5 (1-2016) CORPORATE RESOLUTION AUTHORIZING APPLICATION TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA FOR A CERTIFICATE OF CONSENT TO SELF-INSURE WORKERS' COMPENSATION LIABILITIES At a meeting of the Board of Directors of ______________________________________________________________________ (Name of Corporation) a corporation organized under the laws of the State of __________________________ held on the _______day of ___________________ 20_____, a quorum being present, the following Resolution was adopted: RESOLVED that the above named corporation is authorized to make application for a Certificate of Consent to Self-Insure Workers' Compensation liabilities to the Department of Industrial Relations of the State of California, and any corporate officer of said corporation is authorized to bind corporation and execute any and all required documents for such application. CERTIFICATE OF SECRETARY The Secretary of the Corporation hereby certifies that the above is a true and correct record of the resolution that was duly adopted by the Corporation as indicated above. ____________________________________ Secretary Dated: ______________________________ American LegalNet, Inc. www.FormsWorkFlow.com