Form 45664 - Application For Real Estate Appraiser Permit For Temporary Practice - Indiana Professional Licensing Agency Page 2
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1
2NOTARY CERTIFICATE
STATE OF ________________________________________________
SS:
COUNTY OF ________________________________________________
I, _______________________________________________, first being duly sworn on oath, say that I am the above-named applicant, that I have personally
prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signa ture of applicant
S ignature of Notary P ublic
Printed or typed na me of applicant
P rinted or typed name of Notary P ublic
Da te subscr ibed and swo rn to Nota ry Pub lic
Coun ty of residen ce
Date commission expire s
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