Fill - Free fillable Austin County Sheriffs Office PDF form

PHS 1/1/14

Austin County Sheriff’s Office

417 N. Ch

esley St.

Bellville, TX 77418

979-865-3111

(Fax)

979-865- 8271

Application for Employment

The attached Personal History Statement (PHS) is what TCOLE considers to be the minimum information

necessary to meet the required Background Investigation (BI) for any Peace Officer, Jailer, or

Telecommunicator appointed to an agency, as defined under TCOLE Rule 211.1(a)(8).

I am applying for:

[ ] Peace Officer PID#_______________

[ ] County Jailer PID#_______________

[ ] Telecommunicator PID#_______________

[ ] Civilian Employment

Name________________________________________________________________________

Date Applied__________________________________________________________________

Telephone Number(s)__________________________ Cell____________________________

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

2

AUTHORITY TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

I

hereby authorize the Austin County Sheriff’s Office and its authorized representatives bearing this release, or a copy thereof,

within one year of its date, to obtain any information in your files pertaining to my employment, military, credit, education or

medical records, including not limited to academic, achievement, attendance, athletic, personal history, and disciplinary records,

medical records, and credit records.

I

hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and

understanding that the information is for official use. Consent is granted to all parties to furnish such information, as described

above, to third parties in the course of fulfilling its official responsibilities. I hereby release you, as custodian of such records,

and any school, college, university, or other educations institution, hospital, or other repository of medical records, credit bureau,

lending institution, consumer reporting agency, or retail business establishment including its officers, employees, or related

personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time

result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or

attempt to comply with it.

I am furnishing my Social Security Account Number on a voluntary basis with the understanding such is not required by any law

or regulation. I have been advised that all parties will utilize this number only to facilitate the location of employment, military,

credit, and educational records concerning me in connection with this application. Should there be any question as to the validity

of this release, you may contact me as indicated below:

A

pplicant’s Printed Full Name: ______________________________________

Address: _______________________________________________________

_______________________________________________________

Telephone Number: _____ _______________________

A

pplicant’s Notarized Signature: _____________________________________

S

worn to and signed before me, on this the _______ day of __________, ___________,

in and for __________________ county, in the state of _____________________ .

Signature of Notary Public: _________________________________________

Printed Name of Notary Public: ______________________________________

My Commission Expires: __________________________

NOT

ARY SEAL

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Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

3

Please include the following documents as applicable.

All original documents will be returned after initial review.

□ Birth Certificate (original)

□ Release

□ Driver’s License

□ High School Diploma or

GED Certificate (original) or

High School Transcript (original)

□ College Diploma/ Transcripts

□ Marriage Certificate

□ Dissolution of Marriage Papers

□ Military Discharge Papers

(DD 214)

□ Peace Officer License

□ Social Security Card

□ Credit Report

(www.annualcreditreport.com)

□ Other _________________

PLEASE NOTE: PAGE 2 OF THIS APPLICATION REQUIRES A NOTARIZED SIGNATURE.

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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BACKGROUND INQUIRY RELEASE

I understand that the Austin County Sheriff’s Office will be conducting a background investigation on myself,

including but not limited to identity and prior address(es) verification, criminal history, driving history, credit

history, medical history, education verification, licensing verification, prior employment verification, work and

other references, as well as any other information that the investigator deems necessary.

I understand that the information and reports developed may include information as to my character, work habits,

job performance and experience, along with reasons for termination of prior employment. I further understand

that for purposes of this background investigation, various sources will be contacted to provide information,

including but not limited to various federal, state municipal, corporate, private and other sources which may

contain records concerning my past activities relating to possible criminal conduct, civil litigation, driving

history and credit performance as well as any other information the investigator feels is necessary.

I authorize, without reservation, any company, agency, party or other source contacted to furnish the above

information. I also consent to the retrieval of the above information by Austin County. A copy of this release

shall be as valid as the original document. I also understand and agree that all information received by the

Austin County Sheriff’s Office as a result of this investigation connected with my application is confidential and

shall NOT be disclosed to me at any time. I also understand and agree that if I am not selected for the position

applied for, I will not be informed of the reasons why I was not selected.

________________________________ _________/_______/________

Applicant’s Signature Date

________________________________

Print Name

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Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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TEXAS COMMISSION ON LAW ENFORCEMENT

APPLICANT’S PERSONAL HISTORY STATEMENT

Personal History Statement Instructions

E

mployees are exposed to confidential and law enforcement sensitive information. A thorough background investigation is required to

properly evaluate the suitability of applicants for employment with the agency. Although it is an achievement to reach the background

phase of the hiring process, this is still a competitive process and does not, in any way, guaranty selection.

These instructions are provided as a guide to assist you in properly completing your Personal History Statement. It is essential that

the information is accurate in all respects so please read all instructions carefully before proceeding. The Personal History

Statement will be used as a basis for a background investigation that will determine your eligibility for becoming an employee.

1. Your application must be printed legibly in BLACK INK by the applicant or typed. Answer all questions truthfully and

accurately.

2. If a question is not applicable to you, enter N/A in the space provided.

3. Avoid errors by reading the directions carefully before making any entries on the form. Be sure your information is accurate

and in proper sequence before you begin.

4. You are responsible for obtaining correct and full addresses. If you are not sure of an address, personally verify before making

that entry on this history statement. Errors will not be viewed favorably. ALL ADDRESSES MUST BE COMPLETE

WITH ZIP CODES.

5. If you need additional space for your answers, attach an additional sheet or sheets as needed. Be sure to indicate what question

number and page this refers to.

6. An accurate and complete form will help expedite your investigation. Omissions or falsifications will result in

disqualification.

7. You are responsible for furnishing any changes and/or updating your application as needed, such as address changes

or telephone changes in writing.

8. Any candidate submitting an incomplete application WILL NOT BE CONSIDERED FOR EMPLOYMENT. Your

application will be evaluated on completeness and neatness.

9. All documents requested must be submitted with the application. Required documents vary according to the position

being sought and the history of the applicant. Hiring agency please check off documents required- modify list as necessary

 C

ompleted Personal History Statement

 Copy of your Social Security card.

 Original or certified copy of your birth certificate.

 Copy of your valid driver license. Applicant must possess a valid Texas driver license prior to being offered

employment.

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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 Origanal High School diploma or GED certificate.

 Sealed original certified copy of your college transcript.

 College diploma.

 C

opy of your Peace Officer Certificate from your police academy. (Peace Officer Applicants Only)

 Copy of your Texas peace officer license and all training certificates awarded to you. (Peace Officer Applicants

Only)

 Copy of your DD-214 if applicable. Must possess an honorable discharge.

 Original certified copy of your Naturalization papers, if applicable.

 Copy of current proof of automobile liability insurance.

 Copy of a TCOLE approved Firearms Qualifications within the last 12 months.

10. If

you have any questions, please contact your assigned background investigator

11. When submitting the completed documents, please place them in a sealed envelope marked Personal and Confidential to your

assigned background investigator.

Applicant Qualification Section

Before you begin to fill out this personal history statement, please ensure that you meet the following requirements.

You must meet all five of these requirements to qualify for licensure as a peace officer or jailer in Texas.

Initial:

______I am a citizen of the United States of America.

______I have earned a high school diploma or a GED.

______I have never been convicted, plead guilty (nolo contendere), nor have I been on court-

ordered community service/probation or deferred adjudication for a Class A misdemeanor or a

felony.

______During the last ten (10) years, I have not been convicted, plead guilty (nolo contendere),

been on community service/probation or deferred adjudication for a Class B misdemeanor in this

state, other state, or while serving in the military.

______I have never had a military court martial that resulted in a dishonorable or bad conduct

discharge.

DISQUALIFICATION

There are very few automatic basis for rejection. Even issues of prior misconduct, employee terminations, and

arrests are usually not, in and of themselves, automatically disqualifying. However, deliberate misstatements or

omissions can and often will result in your application being rejected, regardless of the nature or reason for the

misstatements/omissions. In fact, the number one reason individuals “fail” background investigations is

because they deliberately withhold or misrepresent job-relevant information from their prospective employer.

This personal history statement is a governmental document. Be truthful, as there are criminal consequences

for lying on a governmental document.

Texas Commission on Law Enforcement Personal History Statement

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APLICANT IDENTIFICATION

INFORMATION PROVIDED IN THIS SECTION IS USED FOR IDENTIFICATION PURPOSES ONLY.

Last Name

First

Middle

Maiden

Street Address

Apt. No.

City

State & Zip Code

Mailing Address (if different from residence)

State & Zip Code

Home Telephone No.

Work Telephone No.

Cellular No.

Pager No.

Date of Birth

Social Security No.

Drivers License No. & State

Have you ever been known or gone by any other name (excluding nick-names)? If yes, give details.

_________________________________________________________________________________________________

Place of Birth (City, County, State, Country) ______

Are you a U.S. Citizen by Birth? Are you a Naturalized Citizen?

Height Weight Eye Color Hair Color

Scars, Tattoos (description and location) or other distinguishing marks

Do you have a social networking, instant messaging, or other internet-based profile(s)? If yes, provide screen name(s),

service provider(s).

List ALL E-Mail Addresses (S) _______________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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MARITAL & FAMILY HISTORY

Single Married Engaged Co-habiting

Spouse’s/Co-habitant‘s name (include maiden name)

Address

Date of Birth Date of Marriage

Employer(s)

Employer & Address

Home Telephone No. Work Telephone No.

Roommate(s)(do not include parents or cohabitants)

Date(s) of birth

If you have been separated, divorced, or widowed, provide details below:

Date of Marriage Date of Marriage

City & State City & State

Separated Date Separated Date

Divorced Date Divorced Date

Widowed Date Widowed Date

Annulled Date Annulled Date

Court or State issued Court or State issued

Ex-spouse’s Name Ex-spouse’s Name

Date of Birth Date of Birth

Telephone No. Telephone No.

Identify children related to you or your spouse (Natural, Step-Children, Adopted, or Foster Children)

Relation

Name

Date of Birth

Address

Texas Commission on Law Enforcement Personal History Statement

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Identify relatives in the following order: Father, Mother (include maiden name), step-parents (if any), brothers and sisters.

Relationship

Name

Complete Address

Phone Number

DOB

RESIDENCES

Identify all residences where you have lived in the last 10 years, beginning with the most recent, including your

present address. List date by month/year. Include military assignments. (No TDY’s)

From

To

Address

City

Sate & Zip code

Texas Commission on Law Enforcement Personal History Statement

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PERSONAL REFERENCES

List five (5) persons who know you well enough to provide current information about you. Do not list relatives, former or

present employers, or supervisors.

Name Years known

Address

Home Telephone Alternate Telephone

Nature of Relationship___________________________

Name Years known

Address

Home Telephone Alternate Telephone

Nature of Relationship___________________________

Name Years known

Address

Home Telephone Alternate Telephone

Nature of Relationship___________________________

Name Years known

Address

Home Telephone Alternate Telephone

Nature of Relationship___________________________

Name Years known

Address

Home Telephone Alternate Telephone

Nature of Relationship___________________________

Identify below any employees of the Texas Commission on Law Enforcement with whom you are acquainted:

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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TRAFFIC RECORD

Identify all vehicles that you currently own or operate:

Year

Make

Model

Color

License Plate No.

Owner

Please list your current automobile insurance carrier: Expires:

Have you ever possessed a driver’s license issued by any state other than Texas? Yes No

If yes, give details below:

Driver’s License No. State Date issued

Have you ever had your driver’s license suspended or revoked? Yes No If yes, give reason, date, and length of

suspension:

Identify all motor vehicle accidents you have been involved in during the last 10 years.

Date

Location

Police Report: Yes/No

Cause of Accident (e.g., ran red light, failed to control speed)

Date

Location

Police Report: Yes /No

Cause of Accident (e.g., ran red light, failed to control speed)

Identify all traffic citations you have received within the last 10 years, excluding parking tickets:

Month/Year

Violation

City & State

Disposition (e.g., defensive driving, dismissed)

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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ARRESTS, DETENTIONS, AND LITIGATION

Have you ever been arrested or detained by law enforcement?

Yes No If yes, complete the following table:

Agency

Offense

Date

Location

Outcome

Have you ever committed an act of family violence? (“Family violence” means an act by a member of a family or

household against another member of the family or household that is intended to result in physical harm, bodily injury,

assault, or sexual assault or that is a threat that reasonably places the member in fear of imminent physical harm, bodily

injury, assault, or sexual assault, but does not include defensive measures to protect oneself.) (Texas Family Code

Section 71.004) If yes, explain:

Have you ever assaulted another person since the age of seventeen (17)? (“Assault” means to cause bodily injury to

another, threaten another with imminent bodily injury, or to cause physical contact with another when the person knows or

should reasonably believe that the other will regard the contact as offensive or provocative.) (Texas Penal Code Section

22.01) If yes, explain:

Have you ever been considered or named a suspect in a criminal investigation or criminal offense? If yes, explain:

Have you ever been a party to a civil suit or action? If yes, explain:

Have you ever been involved in any incident (do not include vehicular accidents) in which a police report was made or law

enforcement was called? If yes, explain:

Other than crimes that would have been sealed by juvenile records, have you ever committed – or assisted another person

in the commission of – a felony crime, serious misdemeanor, or a crime involving moral turpitude that went undetected or

unreported to law enforcement? If yes, explain:

Do you anticipate being sued or named in any type of lawsuit or proceeding? Yes No

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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FAMILY AND RELATIVES’ ARRESTS

Have members of your immediate family or close relatives have ever been arrested?

Yes No If yes, complete the following table:

Name/Relationship

Charge/Offense

Outcome

Year

Agency

FINANCIAL HISTORY

Your current net monthly income Spouse’s current net monthly income

Source Amount Frequency

Do you have any accounts with a financial institution? Yes No

Name(s) of financial institution(s)

Type(s) of account(s)

Identify any person or entity to whom you are indebted, and the extent of your indebtedness. Include mortgages, vehicle

payments, charge accounts, credit cards, loans, child support payments, and any other debts or payments.

Name of Creditor (e.g., Sears, Citi financial)

Type of Debt (e.g., student loan, automobile)

Monthly Payment

Approx Balance

Texas Commission on Law Enforcement Personal History Statement

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CREDIT INFORMATION

Have you ever filed bankruptcy personally or on behalf of a business? Yes______ No______

If “Yes” to above, indicate type

Have you ever had any personal or real property repossessed or foreclosed? Yes______ No______

Have you ever failed to pay Federal, state, or other taxes? Yes______ No______

Have you ever failed to file a tax return, when required by law? Yes______ No______

Have you ever had a lien placed against your property for failing to pay taxes or other debts? Yes______ No______

Have you ever had a judgment entered against you? Yes______ No______

Have you ever defaulted on any type of loan? Yes______ No______

Have you ever had bills or debts turned over to a collection agency? Yes______ No______

Have you ever had any credit account suspended, charged off, or cancelled for failure to pay? Yes______ No______

Have you ever written a check that was later returned for Non Sufficient Funds (NSF)? Yes______ No______

Have you ever been delinquent on court-imposed alimony or child support payments? Yes______ No______

Have you ever been disciplined regarding the use of a travel/credit card provided by an employer? Yes______ No______

Are you currently more than sixty (60) days delinquent on any debts? Yes______ No______

Have you ever applied for unemployment compensation? Yes No When?

Have you ever received unemployment compensation? Yes No When?

Identify any person or entity to which you are more than 30 days late in paying. Include mortgages, vehicle payments,

charge accounts, credit cards, loans, child support payments, and any other debts or payments.

Name of Creditor (e.g., Sears, Citi financial)

Type of Debt (e.g., student loan, automobile)

Number of Days Late

Reason

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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EMPLOYMENT HISTORY

Beginning with your present or most recent job, list all employment since the age of seventeen (17). Include full-time, part-

time, temporary, seasonal, military assignments, or unpaid internships, plus all periods of unemployment.

If you are currently employed, may we contact your present employer? Yes No

1. Employer From To

Address

Telephone No.

Job Title Beginning and Ending Salary ________________/__________________

Work Schedule

Name of supervisor Supervisor contact information __________________________

Name of a co-worker Co-worker contact information

Duties: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Identify any disciplinary actions you received:

Reason for Leaving:

Was there an unemployment period between previous employment and the one listed above? _____Yes ____No

If yes, provide dates and explain: __________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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2. Employer From To

Address

Telephone No.

Job Title Beginning and Ending Salary ________________/__________________

Work Schedule

Name of supervisor Supervisor contact information __________________________

Name of a co-worker Co-worker contact information

Duties: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Identify any disciplinary actions you received:

Reason for Leaving:

Was there an unemployment period between previous employment and the one listed above? _____Yes ____No

If yes, provide dates and explain: __________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

PHS 01/01/14

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3. Employer From To

Address

Telephone No.

Job Title Beginning and Ending Salary ________________/__________________

Work Schedule

Name of supervisor Supervisor contact information __________________________

Name of a co-worker Co-worker contact information

Duties: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Identify any disciplinary actions you received:

Reason for Leaving:

Was there an unemployment period between previous employment and the one listed above? _____Yes ____No

If yes, provide dates and explain: __________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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4. Employer From To

Address

Telephone No.

Job Title Beginning and Ending Salary ________________/__________________

Work Schedule

Name of supervisor Supervisor contact information __________________________

Name of a co-worker Co-worker contact information

Duties: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Identify any disciplinary actions you received:

Reason for Leaving:

Was there an unemployment period between previous employment and the one listed above? _____Yes ____No

If yes, provide dates and explain: __________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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5. Employer From To

Address

Telephone No.

Job Title Beginning and Ending Salary ________________/__________________

Work Schedule

Name of supervisor Supervisor contact information __________________________

Name of a co-worker Co-worker contact information

Duties: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Identify any disciplinary actions you received:

Reason for Leaving:

Was there an unemployment period between previous employment and the one listed above? _____Yes ____No

If yes, provide dates and explain: __________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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6. Employer From To

Address

Telephone No.

Job Title Beginning and Ending Salary ________________/__________________

Work Schedule

Name of supervisor Supervisor contact information __________________________

Name of a co-worker Co-worker contact information

Duties: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Identify any disciplinary actions you received:

Reason for Leaving:

Was there an unemployment period between previous employment and the one listed above? _____Yes ____No

If yes, provide dates and explain: __________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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7. Employer From To

Address

Telephone No.

Job Title Beginning and Ending Salary ________________/__________________

Work Schedule

Name of supervisor Supervisor contact information __________________________

Name of a co-worker Co-worker contact information

Duties: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Identify any disciplinary actions you received:

Reason for Leaving:

Was there an unemployment period between previous employment and the one listed above? _____Yes ____No

If yes, provide dates and explain: __________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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8. Employer From To

Address

Telephone No.

Job Title Beginning and Ending Salary ________________/__________________

Work Schedule

Name of supervisor Supervisor contact information __________________________

Name of a co-worker Co-worker contact information

Duties: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Identify any disciplinary actions you received:

Reason for Leaving:

Was there an unemployment period between previous employment and the one listed above? _____Yes ____No

If yes, provide dates and explain: __________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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EDUCATIONAL HISTORY

High School(s) attended

Address

Dates attended

From-To

Graduated

Yes/No

Do you have a G.E.D. Certificate?

Were you ever expelled from school? If yes, give details:

Identify all colleges, universities, or technical schools you have attended:

Name

City & State

Dates attended

Hours completed

Major

Degree & Date

MILITARY OBLIGATION

Have you ever served in the U.S. Armed Forces or State Military Forces? Yes No

Served from to Highest Rank held

Date Date

Branch of Service Unit

Job Title(s) (e.g., Rifleman, Security)

Type of discharge___________________ Last Duty Station: _______________________________

Are you actively serving in a Reserve Unit (including State Military Forces)? Yes No

Serving from to Current Rank held

Date Date

Branch of Service Unit

Job Title(s) (e.g., Rifleman, Security)

Have you ever been subject to court martial or any other disciplinary proceeding under the Uniform Code of Military

Justice? (Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s), charge(s), military court(s) or authority(ies),

and outcome(s).

_________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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SPECIAL QUALIFICATIONS & SKILLS

Identify any special licenses you hold (e.g., pilot, radio operator):

If you know a foreign language, indicate your fluency in each block below (excellent, good, fair)

Language

Understanding

Speaking

Reading

Writing

Do you have any experience with firearms? Yes No

MEMBERSHIP IN ORGANIZATIONS (PAST AND PRESENT)

Name & Address

Type (e.g., social, fraternal, professional)

From

To

Have you ever been an officer or a member of, or made a contribution to, an organization that advocates or practices the

commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or right

granted by law. Yes_______ No_______

PERSONAL DECLARATIONS

Do you consume alcoholic beverages? Yes No If “Yes”, how often? _________________

Have you ever used marijuana or hashish? Yes No If yes, when last used?

Have you ever used any illegal drug (including a performance-enhancing steroid) not prescribed by a physician?

Yes No If yes how often___________ When last used______________

Provide explanation:

Have you ever sold or furnished controlled substances or prescription drugs to anyone? Yes No

If yes, give details:

Is it against any of your personal beliefs to take a human life in the line of duty? No___________

Yes (please explain)_________________________________________________________________________________

Are there any incidents in your life, or details not mentioned herein, which may influence this department’s evaluation of

your suitability for employment as a police officer?

If yes, explain:

____________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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Have you ever been employed by or applied with any other law enforcement agency? Yes No

If yes, please identify to the best of your knowledge:

Agency Name & Address

Date Applied or Hired

Result

Is there any reason why you would not be able to work nights, weekends or holidays? No___________ Yes__________

Identify any additional information you think should be considered in your application for the position you are seeking,

and/or any further explanation of answers to previous questions:

Any additional information you believe did not fit elsewhere on this form:________________________________________

_________________________________________________________________________________________________

________________________________________________________________________________________________

Texas Commission on Law Enforcement Personal History Statement

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I hereby certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and answers

to the above questions. I fully understand that any misrepresentation, omission, or falsification may deem me permanently

unsuitable, or if hired, may lead to the termination my employment.

Signature of applicant

Date

Before me personally appeared who stated this document and its

intent was explained to him/her that he/she has full knowledge of its purpose and that he/she executed this instrument of

his/her free will and accord.

Sworn to and subscribed before me on this day of ,

_____________________________________________

SEAL or STAMP Signature of Notary

My Commission Expires: _________________________

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