STATE OF NORTH CAROLINA                                                         IN THE GENERAL COURT OF JUSTICE
COUNTY OF SAMPSON                                                                    DISTRICT COURT DIVISION
                                                                                            FILE NO. _________________
                                                                                            FILM NO. _________________



STATE OF NORTH CAROLINA,       
PLAINTIFF                        
                                                                        WRITTEN WAIVER OF APPEARANCE
VS.                                                                                     PURSUANT TO G.S. 15A-1011(a)(3)
                                       
_______________________________________,                    
DEFENDANT        


Pursuant to N.C.G.S 15A-1011(d), the undersigned Defendant does hereby waive Defendant's

appearance in the above captioned case and agrees to be bound by the decision of the Court; further

that the Defendant is unable  to appear at the time of setting of said case and does hereby request that

the State proceed under the Section herein above cited; that the undersigned Defendant does further

designate R. M. Holland, Jr., Attorney at Law, to appear on Defendant's behalf and to enter a plea to the

offense as charged or such other lesser offenses as may be charged in a plea bargain arrangement with

the State.


This the ______ day of _______________________, 200__.



                                                ___________________________________
                                                Defendant