State of _______________________________
County of _______________________________
By: _______________________________
(Name) _______________________________
(Address) _______________________________
being duly sworn, depose(s) and say(s) that the contents of this application are true to the best of (his or her) knowledge or belief. The undersigned Applicant(s) has (have) signed the application this ____ day of __________________, 2______.
_______________________________
(Applicant(s))
By: _______________________________
Subscribed and sworn to before me, a [Notary Public, or title of other official authorized by the state to notarize documents, as appropriate] this ____ day of ____________________, 2______.
/SEAL [if any]
(Notary Public, or other authorized official)
18 C.F.R. §5.18