Dh 1322 - Application For Radioactive Materials License Page 4

Florida Bureau of Radiation Control - Application For Radioactive Materials License

HUMAN USE

35. CERTIFICATE

The applicant and any official executing this certificate on behalf of the applicant named in Item 1, certify

that this application has been prepared in accordance with Chapter 64E-5, Florida Administrative Code,

and that all information contained herein, including any supplements attached hereto, is true and correct

to the best of our knowledge and belief. In addition, the applicant or executing official is acknowledging

that they are aware that knowingly making false statements to a public servant is a violation of section

837.06, Florida Statutes, and is punishable by fine or imprisonment

Certifying Official (Signature)

Name (typed or printed)

Title

Date

Warning:

KNOWINGLY MAKING FALSE STATEMENTS TO A PUBLIC SERANT IS A VIOLATION OF

SECTION 837.06, FLORIDA STATUTES, AND IS PUNISHABLE BY FINE OR IMPRISONMENT

DH 1322, 12/09 (Rule 64E-5.207, F.A.C.)

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