HAND DSET T BLA ACKLIISTIN NG RE EQUE EST FO ORM
I confirm th hat the above detailss are corre ect to the b best of my knowledge. I agree and a understand that t I am b bound by my m conscien nce in giving these details d and that any misreprese m entation orr an in ncorrect sttatement of o the deta ails and faccts is fraud d. I had the e opportun nity to ask questionss about a this fform, and I understa and this form and the e effect it has on myy rights.