ALASKA WORKERS' COMPENSATION BOARD P.O. Box 115512 JUNEAU, ALASKA 99811-5512 ,) ) Employee, vs. Employer, and ) ) ) ,) ) ) ) ) ,) ) Its workers' compensation insurance carrier and/or adjuster. ) ) ) NOTICE OF APPEARANCE Name Address Telephone Number enters an appearance as the representative of I am / I am not an attorney licensed to practice law within the State of Alaska. This section must be completed if the representative is not an attorney licensed to practice law within the State of Alaska. I, , authorize Date Date to represent me in this case. . AWCB Case No.: SIGNATURE of the party being represented SIGNATURE of the representative filing this Notice of Appearance ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------PROOF OF SERVICE: I certify that a true and correct copy of this notice has been served upon the Alaska Workers' Compensation Board (AWCB) and all parties to this case or, if a party is represented, upon the party's representative, as listed below; you must include: (1) the name of the person(s) served, (2) the method of service: personally, by mail, electronically, or facsimile, (3) the place of personal service or mailing address served, or if service was electronically or by facsimile, proof of transmission, and (4) your signature and the date of service. SIGNATURE of the person serving this Notice of Appearance Form 07-6116 (Rev 02/2011) Date of Service American LegalNet, Inc. www.FormsWorkFlow.com