I owner of property located on ____________________________,
(Name) (Street Name)
recorded in
and having a parcel identification number of _________,
(Deed Book/Page) (PIN)
located in Henderson County, North Carolina, do hereby appoint ,
(Agent’s Name)
to represent me in an application to the Planning Department and authorize him/her to act as my
agent in all matters, formal and informal except as stated herein, and authorize him/her to receive all
official correspondence.
I however understand that as the listed property owner, I must sign all affidavits and statements
required by any applicable ordinance.
Property Owner Date