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AFFIDAVIT and RELEASE AUTHORIZATION

I am the applicant described and identified in this application for licensure, certification, or registration in the State of Utah.

I am qualified in all respects for the license, certificate, or registration for which I am applying in this application.

To the best of my knowledge, the information contained in the application and its supporting document(s) is free of fraud,

misrepresentation, or omission of material fact.

To the best of my knowledge, the information contained in the application and its supporting document(s) is truthful, correct, and

complete; and, discloses all material facts regarding the applicant and associated individuals necessary to properly evaluate the applicant’s

qualifications for licensure.

I will ensure that any information subsequently submitted to the Division of Occupational and Professional Licensing in conjunction with

this application or its supporting documents meet the same standard as set forth above.

I understand that it is unlawful and punishable as a class A misdemeanor to apply for or obtain a license or to otherwise deal with the

Division of Occupational and Professional Licensing or a licensing board through the use of fraud, forgery, or intentional deception,

misrepresentation, misstatement, or omission.

I understand that this application will be classified as a public record and will be available for inspection by the public, except with regard

to the release of information which is classified as controlled, private, or protected under the Government Records Access and

Management Act or restricted by other law.

I authorize all persons, institutions, organizations, schools, governmental agencies, employers, references, or any others not specifically

included in the preceding characterization, which are set forth directly or by reference in this application, to release to the Division of

Occupational and Professional Licensing, State of Utah, any files, records, or information of any type reasonably required for the Division

of Occupational and Professional Licensing to properly evaluate my qualifications for licensure/certification/registration by the State of

Utah.

Signature of Responsible Party:

Date of Signature: ____/____/____

Printed Name of Responsible Party:

COMPLIANCE WITH UTAH LAWS AND RULES

All individuals associated with or employed by the applicant understand that it is their continuing responsibility to read, understand, and

apply the requirements contained in all statutes and rules pertaining to the occupation or profession for which you are applying, and that

failure to do so may result in civil, administrative, or criminal sanctions.

Name: ____________________________________ Signature: ____________________________________ Date: __________

DOPL-AP- Rev 2013-03-18

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