Are you interested in attending the CG 10R conference, but not sure how to go about registering? This blog post will provide you with all the information you need on the application process, including what materials are required and when the deadline is. So whether you're a seasoned pro or a first-time attendee, read on for everything you need to know!
Question | Answer |
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Form Name | Cg 10R Application Form |
Form Length | 5 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 15 sec |
Other names | form cg 10, cg 10 application form, application for renewal cg 10r, Alaska |
C G - 10 R A PPLIC ATIO N FO R RENEWAL O R REINSTATEMENT O F A FLO RIDA EDUC ATO R’S PRO FESSIO NAL C ERTIFIC ATE
Iorulgd#Ghsduwphqw#ri#Hgxfdwlrq#
Bure a u o f Ed uc a to r C e rtific a tio n Ro o m 201, Turling to n Build ing
325We st G a ine s Stre e t
Wdoodkdvvhh/#IO#656<<03733#
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O ffic ia l Use O nly |
FLDO E Da te Sta m p |
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PA |
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PM |
C K |
C A |
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VO |
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PN |
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AFF |
Ye s |
No |
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P E R S O N A L I N FO R M A TI O N |
Co m p le te e ntire Ap p lic a tio n in UPPERC ASE le tte rs using o nly b lac k o r b lue ink. |
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1. So c ia l Se c urity Num b e r |
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2 . Birth Da te ( MM / DD / YYYY ) |
3 . A re yo u a US C itize n? |
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M |
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Y |
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Y |
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Ye s |
No |
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4 . First Na m e |
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81#Plggoh#Qdph# |
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6 . La st Na m e
:1#Pdlolqj#Dgguhvv#
8 . C ity |
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9. Sta te |
431#]ls#Frgh# |
11. Pho ne |
12 . C o untry
461#H0pdlo#Dgguhvv=#
471#Zkdw#lv#|rxu#jhqghuB#+Rswlrqdo,#
MF
15 . A re yo u Hisp a nic o r La tino?
+Rswlrqdo/#fkrrvh#rqo|#rqh,#
No , no t Hisp a nic o r La tino
Ye s, Hisp a nic o r La tino
16 . Wha t is yo ur ra c e ?
+Rswlrqdo/#pdun#doo#wkdw#dsso|,#
Ame ric a n Ind ia n o r Ala ska Na tive
Asia n
Bla c k o r Afric a n Ame ric a n
Qdwlyh#Kdzdlldq#ru#Rwkhu#Sdflilf#Lvodqghu# Zklwh#
RE N E W A L O R R E I N S TA TE M E N T RE Q U E S TE D
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Se rvic e |
Ghvfulswlrq#ri#Vhuylfh#Uhtxhvwhg# |
Fe e |
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RENEWAL |
L#zdqw#wr#dsso|#iru#UHQHZDO#ri#p|#Iorulgd#Surihvvlrqdo#Fhuwlfdwh#zklfk#kdv#qrw#|hw# |
$75.00 |
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e xp ire d . |
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LATE RENEWAL |
L#zdqw#wr#dsso|#iru#ODWH#UHQHZDO#ri#p|#Iorulgd#Surihvvlrqdo#Fhuwlfdwh#zklfk#kdv# |
$105.00 |
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uhfhqwo|#h{sluhg#+qrw#pruh#wkdq#rqh#|hdu,1# |
+':8#soxv#'63#Odwh#Ihh,# |
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REINSTATEMENT |
L#zdqw#wr#dsso|#iru#UHLQVWDWHPHQW#ri#p|#h{sluhg#Iorulgd#Surihvvlrqdo#Fhuwlfdwh1# |
$75.00 |
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yxwvutsrponC o urse Num b e rNa m e o f Institutio n |
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S U B J E C TS R E N E W E D O R R E I N S TA TE D |
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Olvw#Vxemhfw+v,#vkrzq#rq#|rxu#Surihvvlrqdo#Fhuwlfdwh#wkdw#duh#wr#eh#Uhqhzhg#ru#Uhlqvwdwhg# |
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Phwkrg#ri#Uhqhzdo# |
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Sub je c t(s) |
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Wr#Eh#Uhqhzhg# |
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C lle g e C re d it |
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Flo rid a Inse rvic e C re d it |
FL Sub je c t |
NBPTS |
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ru#Uhlqvwdwhg# |
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Num b e r o f Po ints |
Are a Te st |
Fhuwlfdwh |
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TE A C H I N G E X P E R I E N C E R E C O R D (Sub stitute te a c hing e xp e rie nc e is no t a p p ro p ria te .)
Olvw#Whdfklqj#H{shulhqfh#Vlqfh#Odvw#Fhuwlfdwh#Lvvxhg#
Da te s o f Em plo ym e nt |
Na m e o f Em plo ye r |
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(MM/DD/YYYY) |
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Be g in |
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Hqg# |
Sc ho o l Na m e |
C o unty |
Sta te |
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Sub je c t
Judgh#
Le ve l
Full- Tim e Pa rt- Tim e
Pub lic o r Priva te Sc ho o l
L E G A L D I S C LO S U R E
Iorulgd#Odz#uhtxluhv#|rx#wr#surylgh#d#\HV#ru#QR#dqvzhu#wr#wkh#txhvwlrqv#zlwklq#wkh#Ohjdo#Glvforvxuh#vhfwlrq#ri#|rxu#dssolfdwlrq/#hyhq#li#suhylrxvo|#
vxeplwwhg1# Wkh#Digdylw#vhfwlrq#pxvw#eh#frpsohwhg#zlwk#|rxu#vljqdwxuh#erwk#wlphv#lw#rffxuv#zlwklq#wkh#irup/#mxvw#ehorz#dqg#dw#wkh#hqg#ri#wkh#Ohjdo#
Disc lo sure Sup p le m e nt, fo r yo ur a p p lic a tio n to b e c o m p le te .
A F F I D A V I T
L/bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb/#gr#khuhe|#fhuwli|#wkdw#L#vxevfuleh#wr#dqg#zloo#xskrog#wkh#sulqflsohv#lqfrusrudwhg#lq#
PRINT NAME
wkh#Frqvwlwxwlrq##ri#wkh#Xqlwhg#Vwdwhv#ri#Dphulfd#dqg#wkh#Frqvwlwxwlrq#ri#wkh#Vwdwh#ri#Iorulgd1
L#gr#khuhe|#diilup#wkdw#doo#lqirupdwlrq#surylghg#lq#p|#dssolfdwlrq#iru#d#Iorulgd#Hgxfdwruᄋv#Fhuwlilfdwh#lv#wuxh/#dffxudwh/#dqg#frpsohwh1
ZDUQLQJ=# # JLYLQJ# IDOVH# LQIRUPDWLRQ# LQ# RUGHU# WR# REWDLQ# RU# UHQHZ# D# IORULGD# HGXFDWRUᄋV# FHUWLILFDWH# LV# D# FULPLQDO# RIIHQVH#
UNDER FLO RIDA LAW. A NYO NE G IVING FA LSE INFO RMATIO N O N THIS A FFIDAVIT IS SUBJEC T TO C RIMINA L PRO SEC UTIO N, A S WELL A S DISC IPLINA RY AC TIO N BY THE EDUC ATIO N PRAC TIC ES C O MMISSIO N.
bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
bbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
APPLICANT’S SIGNATURE |
DATE |
O F F I C I A L U S E O N LY
I N S E RV I C E C R E D I T
Lqvhuylfh#Fuhglw#Frpsohwhg#Wkurxjk#dq#Dssuryhg#Iorulgd#Pdvwhu#Lqvhuylfh#Surjudp# |
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Qdph#ri#Glvwulfw#ru#Vfkrro#Rujdql}dwlrq=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb#yxwvutsrpon |
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L#khuhe|#yhuli|#wkdw#wkh#dssolfdqw#vdwlvidfwrulo|#sduwlflsdwhg#lq#dq#dssuryhg#Iorulgd#Pdvwhu#Lqvhuylfh#Surjudp#dqg#hduqhg#bbbbbbbbbbsrlqwv#wr# |
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uhqhz#wkh#vxemhfwv#vkrzq#rq#suhfhglqj#sdjh1 |
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#############Vwduwlqj#Gdwh=#bbbbb2bbbbb2bbbbbb# |
Hqglqj#Gdwh=#bbbbb2bbbbb2bbbbbb# |
Inc lud e s “ Ba nke d ” Inse rvic e Po ints |
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(CHECK HERE,# |
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MM DD |
YYYY |
MM DD YYYY |
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bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
bbbbbbbbbbbbbbbbbbbbbb# |
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SIGNATURE OF AUTHORIZED |
SCHOOL OFFICIAL |
POSITION |
DATE |
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E M P LO Y E R D A TE S TA M P
Sd|phqw#Lqfoxghg#
Am o unt
Phwkrg#
Num b e r
###########'#bbbbbbbbbbbbbb#
C K
MO
bbbbbbbbbbbbbbbbbb#
C G - 10 R A PPLIC ATIO N FO R RENEWAL O R REINSTATEMENT O F A FLO RIDA EDUC ATO R’S PRO FESSIO NAL C ERTIFIC ATE
Iorulgd#Ghsduwphqw#ri#Hgxfdwlrq#
Bure a u o f Ed uc a to r C e rtific a tio n Ro o m 201, Turling to n Build ing
325We st G a ine s Stre e t
Wdoodkdvvhh/#IO#656<<03733#
P E RS O N A L I N FO R M A TI O N
Co m p le te in UPPERC ASE le tte rs using o nly b lac k o r b lue ink.
So c ia l Se c urity Num b e r
First Na m e
La st Na m e
LE G A L D I S C LO S U R E #+Iorulgd#Odz#uhtxluhv#|rx#wr#surylgh#d#\HV#ru#QR#uhvsrqvh,#
Diwhu#dqvzhulqj#hdfk#ri#wkh#iroorzlqj#txhvwlrqv/#|rx#pxvw#vljq#wkh#Diilgdylw#wr#frpsohwh#wklv#vhfwlrq#ri#|rxu#dssolfdwlrq1##Ple a se re fe r to
wkh#lqvwuxfwlrqv#lq#wkh#Ohjdo#Glvforvxuh#Vxssohphqw#rq#wkh#uhyhuvh#vlgh#ri#wklv#sdjh#iru#dgglwlrqdo#lqirupdwlrq#uhjduglqj#wklv#vhfwlrq#ri#wkh#
a p p lic a tio n fo rm .
SEA LED O R EXPUNG ED REC O RDS +Uhsruw#RQO\#vhdohg#ru#h{sxqjhg#uhfrugv#lq#wklv#vhfwlrq,#
Fo r e a c h o f the fo llo wing q ue stio ns, if yo ur a nswe r is YES, p le a se se le c t YES. O the rwise , se le c t NO .
YES |
NO |
Kdyh#|rx#hyhu#kdg#dq|#uhfrug#vhdohg#ru#h{sxqjhg#lq#zklfk#|rx#zhuh#frqylfwhg o f a c rim ina l o ffe nse ? |
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YES |
NO |
Kdyh#|rx#hyhu#kdg#dq|#uhfrug#vhdohg#ru#h{sxqjhg#lq#zklfk#|rx#zhuh#irxqg#jxlow| o f a c rim ina l o ffe nse ? |
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YES |
NO |
Kdyh#|rx#hyhu#kdg#dq|#uhfrug#vhdohg#ru#h{sxqjhg#lq#zklfk#|rx#kdg#dgmxglfdwlrq#zlwkkhog o n a c rim ina l o ffe nse ? |
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YES |
NO |
Kdyh#|rx#hyhu#kdg#dq|#uhfrug#vhdohg#ru#h{sxqjhg#lq#zklfk#|rx#sohg#qror#frqwhqghuh to a c rim ina l o ffe nse ? |
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YES |
NO |
Kdyh#|rx#hyhu#kdg#dq|#uhfrug#vhdohg#ru#h{sxqjhg#lq#zklfk#|rx#sohg#jxlow| to a c rim ina l o ffe nse ? |
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YES |
NO |
Kdyh#|rx#hyhu#kdg#dq|#uhfrug#vhdohg#ru#h{sxqjhg#lq#zklfk#|rx#hqwhuhg#lqwr#d#suhwuldo#glyhuvlrq#surjudp o r ghihuuhg# |
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p ro se c utio n p ro g ra m re la te d to a c rim ina l o ffe nse ? |
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YES |
NO |
Gr#|rx#kdyh#d#shwlwlrq#shqglqj#wr#vhdo#ru#h{sxqjh#dq|#fulplqdo#riihqvh#uhfrugB# |
SEA LED o r EXPUNG ED re c o rd s MUST BE REPO RTED#sxuvxdqw#wr#vv1#<76138;8#dqg#<76138</#Iorulgd#Vwdwxwhv1##Krzhyhu/#h{lvwhqfh#ri#vxfk#uhfrugv#
WILL NO T BE DISC LO SED#qru#pdgh#sduw#ri#|rxu#fhuwlilfdwlrq#iloh#zklfk#lv#sxeolf#uhfrug1
C RIMINA L O FFENSE REC O RD(S) +Uhsruw#dq|#uhfrug#rwkhu#wkdq#vhdohg#ru#h{sxqjhg#lq#wklv#vhfwlrq1,
Fo r e a c h o f the fo llo wing q ue stio ns, if yo ur a nswe r is YES, p le a se se le c t YES. O the rwise , se le c t NO .
YES |
NO |
Ha ve yo u e ve r b e e n frqylfwhg o f a c rim ina l o ffe nse ? |
YES |
NO |
Ha ve yo u e ve r b e e n irxqg#jxlow| o f a c rim ina l o ffe nse ? |
YES |
NO |
Kdyh#|rx#hyhu#kdg#dgmxglfdwlrq#zlwkkhog o n a c rim ina l o ffe nse ? |
YES |
NO |
Ha ve yo u e ve r p le d qror#frqwhqghuh to a c rim ina l o ffe nse ? |
YES |
NO |
Ha ve yo u e ve r sohg#jxlow| to a c rim ina l o ffe nse ? |
YES |
NO |
Ha ve yo u e ve r e nte re d into a suhwuldo#glyhuvlrq#surjudp o r ghihuuhg#survhfxwlrq#surjudp re la te d to a c rim ina l o ffe nse ? |
YES |
NO |
Duh#wkhuh#fxuuhqwo|#fkdujhv#shqglqj a g a inst yo u fo r a ny c rim ina l o ffe nse ? |
PRO FESSIO NA L LIC ENSE O R C ERTIFIC ATE SA NC TIO N(S)
Fo r e a c h o f the fo llo wing q ue stio ns, if yo ur a nswe r is YES, p le a se se le c t YES. O the rwise , se le c t NO .
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
Kdyh#|rx#hyhu#kdg#d#surihvvlrqdo#olfhqvh#ru#fhuwlilfdwh#vdqfwlrqhg#ru#glvflsolqhg#lq#wklv#vwdwh#ru#dq|#rwkhu#vwdwhB#
Kdyh#|rx#hyhu#ehhq#GHQLHG#d#surihvvlrqdo#olfhqvh#ru#fhuwlilfdwh#lq#wklv#vwdwh#ru#dq|#rwkhu#vwdwh#hyhq#li#wkh#fhuwlilfdwh#ru# olfhqvh#zdv#odwhu#lvvxhg#zlwk#frqglwlrqv#ru#olplwdwlrqvB
Kdyh#|rx#hyhu#kdg#d#surihvvlrqdo#olfhqvh#ru#fhuwlilfdwh#vxvshqghg#ru#uhyrnhg#lq#wklv#vwdwh#ru#dq|#rwkhu#vwdwhB#
Kdyh#|rx#hyhu#vxuuhqghuhg/#uhvljqhg/#ru#uholqtxlvkhg#d#surihvvlrqdo#olfhqvh#ru#fhuwlilfdwh#lq#wklv#vwdwh#ru#dq|#rwkhu#vwdwh#
d uring o r fo llo w ing a n inve stig a tio n into a lle g a tio ns o f m isc o nd uc t?
Kdyh#|rx#hyhu#kdg#d#surihvvlrqdo#olfhqvh#ru#surihvvlrqdo#fhuwlilfdwh#glvflsolqhg#lq#wklv#vwdwh#ru#dq|#rwkhu#vwdwh#e|# uhfhlylqj#d#ohwwhu#ri#uhsulpdqg/#ilqh/#suredwlrq#ru#dq|#rwkhu#uhvwulfwlrq#ru#vshfldo#frqglwlrqvB
Gr#|rx#kdyh#dq|#fxuuhqw#lqyhvwljdwlyh#dfwlrq#shqglqj#lq#wklv#vwdwh#ru#dq|#rwkhu#vwdwh#djdlqvw#d#surihvvlrqdo#olfhqvh#ru#
c e rtific a te o r a g a inst a n a p p lic a tio n fo r a p ro fe ssio na l lic e nse o r c e rtific a te ?
Gr#|rx#kdyh#dq|#fxuuhqw#glvflsolqdu|#dfwlrq#shqglqj#lq#wklv#vwdwh#ru#dq|#rwkhu#vwdwh#djdlqvw#d#surihvvlrqdo#olfhqvh#ru#
c e rtific a te o r a g a inst a n a p p lic a tio n fo r a p ro fe ssio na l lic e nse o r c e rtific a te ?
Li#|rx#dqvzhuhg#\HV#wr#dq|#ri#wkh#suhfhglqj#txhvwlrqv/#|rx#pxvw#surylgh#ghwdlohg#frpsohwh#lqirupdwlrq#iru#hdfk a ffirm a tive re sp o nse in the Le g a l Glvforvxuh#Vxssohphqw#rq#wkh#uhyhuvh#vlgh#ri#wklv#sdjh#dqg#vxeplw#lw#dorqj#zlwk#|rxu#dssolfdwlrq#irup1##
L E G A L D I S C LO S U R E S U P P L E M E N T
Iorulgd#Odz#uhtxluhv#|rx#wr#surylgh#d#\HV#ru#QR#dqvzhu#wr#wkh#txhvwlrqv#zlwklq#wkh#Ohjdo#Glvforvxuh#vhfwlrq#ri#|rxu#dssolfdwlrq/#hyhq#li#suhylrxvo|# vxeplwwhg1##Li#|rx#dqvzhuhg#\HV#wr#dq|#txhvwlrq#lq#wkh#Ohjdo#Glvforvxuh#vhfwlrq#rq#wkh#dssolfdwlrq#irup/#|rx#pxvw#surylgh#ghwdlohg#frpsohwh#
lqirupdwlrq#iru#hdfk#diilupdwlyh#uhvsrqvh#zlwklq#wkh#fruuhvsrqglqj#vhfwlrq#lq#wklv#Ohjdo#Glvforvxuh#Vxssohphqw1#
\rx#duh#qrw#uhtxluhg#wr#dfnqrzohgjh#plqru#wudyxwvutsrpoiilf#ylrodwlrqv1##Wkh#fulplqdo#riihqvh#ri#Gulylqj#Xqghu#wkh#Lqioxhqfh#+GXL,#ru#Gulylqj#Zkloh#Lqwr{lfdwhg#
+GZL,#lv#no t#d#plqru#wudiilf#ylrodwlrq#dqg#vkrxog#eh#glvforvhg#rq#wklv#irup1#zyxwvutsrqp Kdylqj#d#fulplqdo#klvwru|#ru#dgplqlvwudwlyh#vdqfwlrq#djdlqvw#d#surihvvlrqdo#olfhqvh#grhv#qrw#dxwrpdwlfdoo|#glvtxdoli|#d#shuvrq#iurp#uhfhlylqj#d#
Iorulgd#Hgxfdwruᄋv#Fhuwlilfdwh/#exw#vxfk#lqflghqwv#zloo#surpsw#d#uhylhz#e|#wkh#Riilfh#ri#Surihvvlrqdo#Sudfwlfhv#Vhuylfhv1##
A p e rso n is lqholjleoh#iru#hgxfdwru#fhuwlilfdwlrq#li#wkh#shuvrq#kdv#ehhq#frqylfwhg#ri#d#glvtxdoli|lqj#riihqvh#a liste d in Se c tio n 1012.315 Flo rid a Sta tute s. Ple a se re fe to zzz1p|iorulgdwhdfkhu1frm fo m o re info rm a tio n.
First Na m e
Plggoh#Qdph#
La st Na m e
Fo rm e r Na m e
A ny O the r La st Na m e s / A lia se s
S E A L E D O R E X P U N G E D R E C O R D ( S )
Flw|#Zkhuh#Duuhvwhg# |
Sta te |
Da te o f A rre st |
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C ha rg e |
Ple a |
Disp o sitio n (o utc o m e ) |
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C R I M I N A L O F F E N S E R E C O R D ( S ) |
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Flw|#Zkhuh#Duuhvwhg# |
Sta te |
Da te o f A rre st |
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C ha rg e |
Ple a |
Disp o sitio n (o utc o m e ) |
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P R O F E S S I O N A L L I C E N S E O R C E R T I F I C A TE S A N C T I O N ( S ) |
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Vwdwh=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
\hdu=# bbbbbbbbbbbbbbbbbb## |
Olfhqvh#ru#Fhuwlilfdwh=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
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Lvvxlqj#Djhqf|=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
Vdqfwlrq#dqg#Uhdvrq=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
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Vwdwh=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
\hdu=# bbbbbbbbbbbbbbbbbb## |
Olfhqvh#ru#Fhuwlilfdwh=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
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Lvvxlqj#Djhqf|=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
Vdqfwlrq#dqg#Uhdvrq=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
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Vwdwh=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
\hdu=# bbbbbbbbbbbbbbbbbb## |
Olfhqvh#ru#Fhuwlilfdwh=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
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Lvvxlqj#Djhqf|=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
Vdqfwlrq#dqg#Uhdvrq=#bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
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A F F I D A V I T
L#gr#khuhe|#diilup#e|#p|#vljqdwxuh#wkdw#doo#lqirupdwlrq#surylghg#lq#wklv#dssolfdwlrq#vhfwlrq#dqg#vxssohphqw#lv#wuxh/#dffxudwh/#dqg#frpsohwh1#
ZDUQLQJ=#JLYLQJ#IDOVH#LQIRUPDWLRQ#LQ#RUGHU#WR#REWDLQ#RU#UHQHZ#D#IORULGD#HGXFDWRUᄋV#FHUWLILFDWH#LV#D#FULPLQDO#RIIHQVH#XQGHU#
FLO RIDA LAW. A NYO NE G IVING FA LSE INFO RMATIO N O N THIS A FFIDAVIT IS SUBJEC T TO C RIMINA L PRO SEC UTIO N, A S WELL A S DISC IPLINA RY AC TIO N BY THE EDUC ATIO N PRAC TIC ES C O MMISSIO N.
bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
bbbbbbbbbbbbbbbbbbbbbbbbbbbbb# |
APPLICANT’S SIGNATURE |
DATE |