SPECIAL POWER OF ATTORNEY

Know all men by these presents:

I, __________ married, of legal age, residing at ____________, do hereby APPOINT

____________, married, of legal age, with residence at _______________, as my true and legal
representative to act for and in my name and stead to perform the following acts:
To coordinate with the relevant department and personnel of ____________ for the processing of
my back pay since my effective resignation as _________ (Please insert position) of ___________on
_________ (date of resignation); and to receive all the amount of money which I am legally warranted to
receive, as well as to receive any amount which the management of___________ would give and would
accrue to my benefit in connection with the aforementioned resignation from work; and to sign all and any
documents to effect the successful receipt of my back pay.
HEREBY GRANTING unto my representative full power and authority to execute and perform
every act necessary to render effective the above-enumerated acts as through I myself performed the
same, and HEREBY APPROVING ALL that he may do by virtue hereof with full right of substitution of his
person and revocation of this instrument.
IN WITNESS WHEREOF, I hereby affix my signature this ______day of __________ 20_____, at
__________________.

_______________________________________ ____________________________
Principal Attorney-In-Fact

ACKNOWLEGMENT

BEFORE ME, personally appeared:

NAME COMPETENT EVIDENCE OF IDENTITY

Known to me and to me known to be the same persons who executed the foregoing instrument and
acknowledged to me that the same is their free and voluntary act and deed.
WITNESS MY HAND AND SEAL, on the date and place first above written.
 NOTARY PUBLIC

Doc. No. ________;

Page No. ________;
Book No. ___________;
Series of 20__________.