Form Oc-403.3 - License Application Page 2
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2IF STOCKHOLDER IS AN INDIVIDUAL, USE THIS FORM OF VERIFICATION
State of New York
)
ss:
County of ________________________)
________________________________________________, being duly sworn, deposes and says that I am
the applicant; that I have duly read and signed the foregoing application; that all the matters contained
herein are true, excepting as to such matters therein stated to be alleged on information and belief and
those matters I believe to be true. In addition, I hereby authorize duly designated employees of the
Workers' Compensation Board to make inquiry into and obtain disclosure of any information required to
obtain verification of any statement made in this application.
____________________________________________
Signature of Stockholder
Sworn to before me this
________day of ______________ 20____
__________________________________
Notary Public
NOTARY'S STAMP
IF STOCKHOLDER IS A CORPORATION USE THIS FORM OF VERIFICATION
State of New York
)
ss
County of ________________________)
_______________________________________, being duly sworn, deposes and says that (s)he is the
_________________________________ (title) of ______________________________(parent corp.), Inc.,
which corporation owns ________% of the shares of _________________________________(subsidiary),
Inc.; that (s)he has duly read the foregoing and that all matters contained therein are true, excepting as to
such matters therein stated to be alleged on information and belief and as to those matters (s)he believes to
be true.
______________________________________________
Signature of Qualifying Officer of Parent Corporation
Sworn to before me this
______day of _____________ 20____
______________________________
NOTARY'S STAMP
Notary Public
OC-403.3 Reverse (2-12)
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