Authority: IC 22-3-1-3
Affected: IC 22-3-8-1; IC 22-3-8-2
Sec. 23.
_____ the undersigned affirms under the penalties for perjury, that the foregoing representations are true: that he or she has been duly admitted to practice law in the Circuit and/or Superior Court of _____ County, Indiana, and in the Supreme Court of the State of Indiana, and is at this time in good standing as a practitioner before said Courts.
__________________________________
Signature of Attorney
__________________________________
Printed Name
__________________________________
Office Address
()
__________________________________
Telephone Number
()
__________________________________
Fax Number
__________________________________
E-mail Address
__________________________________
Attorney #
631 IAC 1-1-23
Renumbered Rule 26 by 1967; 84.
Transferred from the Industrial Board of Indiana ( 630 IAC 1-1-26) to the Worker's Compensation Board of Indiana ( 631 IAC 1-1-23) by P.L. 28-1988, SECTION 121, effective July 1, 1988.