BE IT ACKNOWLEDGED, 

That

of City of

in the State of 

_______________________________________________________________________ ,

the undersigned deponent, being of legal age, does hereby depose and say under oath as follows:

All titles and designations claimed by me are accurate and earned at a school accredited by 
the U.S. Department of Education or a State Licensed School, as described for the appropriate practice of listed therapy/therapies, or licensed profession.

I affirm that the foregoing is true except as to statements made upon information and

Witness my hand under the penalties of perjury this _____ day of ____________  , 20 ____ 

____________________________________________

Signature

Address

Witness