Form Op-1(Nna) - Application For U.s. Department Of Transportation (Usdot) Registration By Non-North America-Domiciled Motor Carriers Page 19

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OMB No.: 2126-0016 Expiration: 01/31/2020

FORM OP-1(NNA) Revised 01/10/2017

Section

APPLICANT'S OATH

APPLICANT'S OATH MUST BE COMPLETED (AND SIGNED) BY APPLICANT

, verify under penalty of perjury, under the laws of the United States of

(First Name)

(Middle Name)

(Last Name)

America, that I understand the foregoing certifications and that all responses are true and correct. I certify that I am qualified and authorized to file this

application. I know that willful misstatement or omission of material facts constitute Federal criminal violations under 18 U.S.C. §§ 1001 and 1621 and that

each offense is punishable by up to 5 years imprisonment and a fine under Title 18, United States Code, or civil penalties under 49 U.S.C. §521(b)(2)(B) and

49 U.S.C. Chapter 149.

I further certify that I have not been convicted in U.S. Federal or State courts, after September 1, 1989, of any offense involving the distribution or possession

of controlled substances, or that if I have been so convicted, that I am not ineligible to receive U.S. Federal benefits, either by court order or operation of law,

pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988 (21 U.S.C. 862).

Signature:

Date:

Title:

FORM OP-1(NNA) Instructions • Page 15 of 16