AUTHORIZATION DOCKET NO.

AUTHORIZATION DOCKET NO.

I, _________________, hereby authorize my attorney, ________________________,
to pay my civil revocation fee to the ______________ County Clerk of Court and obtain my
driver's license.

This is the ___________________, day of ________________, 20_____.

________________________
Defendant's Signature

__________________County
State of North Carolina

I certify that the following person(s) personally appeared before me this day, each acknowledging to
me that he/she voluntarily signed foregoing document for the purpose stated therin and in the capacity
indicated __________________________, name (s) of principle(s))
Date ________________________________ ____________________________________
Notary Public
My Commission Expires: ______________
(Official Seal)