I, (name), being first duly sworn, state upon personal knowledge and under penalty of perjury as follows:

1.  The address of my residence is:

2.  I am employed by:

3.  The address of my employer is:

4.  The telephone number at my place of employment is:

5.  The email address at my place of employment is:

6.  The web address at my place of employment is:

Dated this

day of

, 20

Signature of Applicant:

Signed and sworn before me on

day of

, 20

By

(Printed Name of Applicant)

(seal)

Signature of Notary Public