Certificate of Authority

COMMONWEALTH OF PENNSYLVANIA GOVERNOR'S OFFICE PENNSYLVANIA HUMAN RELATIONS COMMISSION In the matter of: Case No.: Appearing on Behalf of: CERTIFICATE OF AUTHORITY I, ____________________________, complainant in the abovecaptioned proceeding, hereby certify that the above named attorney has my express authority to present my case at public hearing and that I understand I am foregoing my right to be represented at such hearing by an attorney or agent of the Human Relations Commission. I do/do not (circle one) authorize that Commission staff counsel remain involved in this proceeding at public hearing. ____________________________________ Signature ____________________________________ Name (Printed) ____________________________________ P.O. Address ____________________________________ City, State, and Zip Code ____________________________________ Telephone (including area code) ____________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com