9 Va. Admin. Code § 25-590-260:8
[Note: The instructions in brackets are to be replaced by the relevant information and the brackets deleted.]
State of....
County of....
On this [date], before me personally came [owner or operator] to me known, who, being by me duly sworn, did depose and say that she/he resides at [address], that she/he is [title] of [corporation], the corporation described in and which executed the above instrument; that she/he knows the seal of said corporation; that the seal affixed to such instrument is such corporate seal; that it was so affixed by order of the Board of Directors of said corporation; and that she/he signed her/his name thereto by like order.
[Signature of Notary Public]
[Name of Notary Public]
My Commission expires:
9 Va. Admin. Code § 25-590-260:8