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License and Certification Verification

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License/Certification License/Cert.# Issuing

Agency

Issued:

(MM/DD/YY)

Expires:

(MM/DD/YY)

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I,, certify that the above information I have stated on this document submitted by me are true and correct and that I have not knowingly withheld any information that might adversely affect my chance for employment. I also understand that any misrepresentation or omission of fact on this document may be cause for a refusal to hire me or the termination of employment at any time during the period of my employment.

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