Form I-910 - Application For Civil Surgeon Designation Page 6
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7Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
information is complete, true, and correct. I completed this
application based only on information that the applicant
provided to me or authorized me to obtain or use.
Preparer's Signature
9.a. Preparer's Signature
9.b. Date of Signature (mm/dd/yyyy)
Form I-910 12/23/16 N
Page 6 of 7
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