POA Form

Limited Power of Attorney Form

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Alert Program – Remote Client Services

Authorization for “e-Signature”
Limited Power of Attorney

(Please read this document carefully, it will affect your legal rights)

RECITALS

WHEREAS: This Authorization is expressly for Alert Program clients who are participating in the Remote Client Services (RCS) virtual class sessions via the Zoom Meeting Platform and;

WHEREAS: Said clients are willing to allow authorized Alert Program staff to execute all “e-Signature” forms upon their behalf so as to expedite the State of California (DHCS) mandated requirement for DUI Participants to execute said “e-Signature” form as proof of enrollment in the Program as well as upon entering each Virtual Class Session and;

THEREFORE: The Alert Program has made the following provision available to its Clients with this Limited Power of Attorney that the Client shall sign of their own free will as evidenced by their acceptance and signature below:

BE IT ACKNOWLEDGED that I, with a mailing address of: , , California, , the “Principal”, do hereby grant a limited and specific power of attorney to the Alert Program, Inc. of 730 S. Eugene Rd, Palm Springs, California, 92253 as my “Attorney-in-Fact”.

Said Attorney-in-Fact shall have full power and authority to undertake and perform only the following act upon my behalf:

To scan or otherwise capture and use exclusively for the following stated purpose: My "e-signature" for the Alert Programs’ RCS virtual meetings via the Zoom Communications, Inc. meeting platform.

The authority herein shall include any such incidental acts as are reasonably required to carry out and perform the specific authorities granted herein. My Attorney-in-Fact agrees to accept this appointment subject to its terms and agrees to act and perform in said capacity consistent with my best interest, as my Attorney-in-Fact in its discretion, deems advisable.

The Attorney-in-Fact shall be able to have the authority herein beginning and end when the Principal has completed his/her DUI education obligation. Immediately afterwards, this form shall become void in force and effect. In addition, this power of attorney shall immediately be voided upon a revocation form being authorized by the Principal.

This power of attorney is governed by the laws in the State of California and requires a Notary or the signatory of two witnesses.

Electronic Signature Consent(Required)

I understand that by signing below, I am electronically signing this document and agree that my electronic signature is the legal equivalent to my handwritten signature.

E-Signature(Required)

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IP Address

Limited Power of Attorney Form

Alert Program – Remote Client Services

Authorization for “e-Signature”Limited Power of Attorney

RECITALS

Authorization for “e-Signature”
Limited Power of Attorney