Ill. Admin. Code tit. 14, pt. 200, subpt. J, app A, ILLUSTRATION G
I certify under penalty of law that I have read this notification and the exhibits attached hereto and incorporated herein by reference, and know the contents thereof and that the statements therein are true and correct.
Executed at _______________, Illinois _________,__________________________
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(Signature(s) of Franchisor, Subfranchisor or Broker)
(SEAL)
By ______________________________
Title ______________________________
STATE OF | ) | SS |
) | ||
COUNTY OF | ) |
Personally appeared before me this __________ day of, ______________________ the above-named ______________(and) _________________to me known to be the person(s) who executed the foregoing notification (as ______________________and ____________________respectively, of the above-named applicant) and (each) being _______________________ first duly sworn, stated upon oath that said notification, and all exhibits submitted herewith, are true and correct.
________________________________
(Notarial Seal)
________________________________
Notary
Ill. Admin. Code tit. 14, pt. 200, subpt. J, app A, ILLUSTRATION G