1. Affidavit:
State of _____________________________
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County of ___________________________
I _____________________________________________ as _________________________________ swear or affirm that I have
executed this form before a Notary Public, of my own free will and:
a. I have read and understand the items and instructions on this form;
b. My answers (including attachments) are true and complete to the best of my knowledge;
c. I understand that I am subject to administrative, civil or criminal penalties if I give false or misleading answers
d. I authorize all my current and former employers, law enforcement agencies, and any other person to furnish to any
jurisdiction, or any agent acting on its behalf, an information they have, including without limitation my
creditworthiness, character, ability, business activities, educational background, general reputation, history of my
employment and, in the case of former employers, complete reasons for my termination;
e. I have read and understand applicable federal and state law, and will be in compliance at all times;
f. I promise to keep the information contained in this form current and to file accurate supplementary information on
a timely basis.
Signature ________________________________________________________ Date:_____________________________
Subscribed and sworn to before me this ________ day of __________, 20_______.
Notary Public Name:_____________________________________________
Notary Public Signature: ___________________________________________
Appointment expiration___________________
Notary Seal Here:
