Form It-Qbe - Qualified Business Expansion Application Page 6
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6IT-QBE
CERTIFICATION BY APPLICANT
H.
Applicant hereby certifies that all information contained above and in exhibits attached hereto
are true to his/her best knowledge and belief and are submitted for the purpose of obtaining
certification from the Panel.
Date:
Applicant:
By:
Signature of Authorized Officer
Title:
Phone Number:
Subscribed and sworn to before me, a Notary Public in and for said County and State, this____day
of ______, 20__.
My commission expires:
Signature:
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r P
n i
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Resident of
County
State of ________________________________
Submit application to:
Georgia Department of Revenue
1800 Century Center Blvd, Ste 15311
Atlanta, GA 30345
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Parent category: Financial