Form Rpg-A1-97- Application For Registration Mississippi State Board Of Registered Professional Geologists Page 4

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PART C
AFFIDAVIT
In affixing my signature to this application, I warrant that all statements made herein and on the
appended sheets are true and correct to the best of my knowledge, information, and belief. In affixing
my signature to this application, I acknowledge that I read and understand the "Registered
Professional Geologists Practice Act of 1997," the Rules of the Board, and shall adhere to the Code
of Ethics/ Professional Conduct contained therein.
Date:
, 19
.
Signature:
“State of
County/Parish of
Personally appeared before me, the undersigned authority in and for the said county/parish and state,
within my jurisdiction, the within named
, who
acknowledged that (he)(she)(they) has (have) sworn to, subscribed to, and executed, the above and
foregoing instrument on this
day of
, 19
.
Notary Public
My commission expires:
"
(Affix official seal, if applicable)
RPG-A5-97
Page 6 of 54 - October, 1999

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