Appointment Of Counsel {152}

Form 152 Revised 6/3/16 UTAH LABOR COMMISSION Division of Adjudication 160 East 300 South, 3rd Floor P O Box 146615 Salt Lake City, UT 84114-6615 casefiling@utah.gov sgcasefiling@utah.gov ____________________________________ * Petitioner * * APPOINTMENT OF COUNSEL v. * * Date of Occupational Injury/Illness * _____________________________ _______________________________________ Respondent (Employer) * * * ***************************** Petitioner hereby appoints the undersigned as my attorney to represent me in my industrial claim, effective immediately. I understand that I am not required to have an attorney in order to pursue my claim and that any questions I have may be answered, without charge, by representatives at the Labor Commission. I hereby appoint the undersigned as my attorney in this workers' compensation claim. Date _______________________________________ Date __________________________________ ___________________________________________ Print Name of Attorney Bar Number ___________________________________________ Signature of Attorney ___________________________________________ Street Address of Attorney ___________________________________________ City/State/ Zip ___________________________________________ Attorney's Telephone Number ___________________________________________ Attorney's E-Mail Address ______________________________________ Printed Name of Petitioner ______________________________________ Signature of Petitioner ______________________________________ Street Address of Petitioner ______________________________________ City/State/Zip ______________________________________ Petitioner's Telephone Number _______________________________________ Petitioner's E-Mail Address UNSIGNED OR INCOMPLETE FORMS WILL BE RETURNED. American LegalNet, Inc. www.FormsWorkFlow.com