STATE OF CALIFORNIA PUBLIC EMPLOYMENT RELATIONS BOARD

NOTICE OF APPEARANCE FORM

CASE NAME:

v.

CASE NUMBER:

NAME OF PARTY:

DATE FILED:

I, the undersigned party, hereby designate as my representative the person whose name and address appear below, and authorize such representative to appear on my behalf in this proceeding. This designation shall remain valid until I file a written revocation of it with the Public Employment Relations Board.

(Signature) (Name of Representative)

(Printed Name) (Title)

(Title) (Organization

(Date) (Mailing Address)

Consent to Electronic Service and Notice of Electronic Service Address:1

☐ I consent to electronic service of notices and documents in the above-captioned case.

___________________________________________ (E-mail)

(City) (Zip)

(Telephone Number) (Ext.)

(Fax Number)

(BOARD AGENT: ) PERB 920 (11/2014)

(State)