Report Of Apprenticeship Experience (F3-Rae) Apprentice And Sponsor Affidavits printable pdf download

Report Of Apprenticeship Experience (F3-Rae) Apprentice And Sponsor Affidavits

North Carolina State Hearing Aid Dealers and Fitters Board

REPORT OF APPRENTICESHIP EXPERIENCE (F3-RAE)

Apprentice and Sponsor Affidavits

Note: This affidavit is a part of the electronic Report of Apprenticeship Experience Application.

All forms, documents, and submissions, as part of the application process, are covered by this affirmation.

Your electronic application will not be processed until this signed affidavit is received by the Board.

Date of Electronic Application (enter date of submission, if known): ______________

Sponsor Name (PRINT CLEARLY): ______________________________________________________

License Number: _________

Registered Sponsor Certificate Number: ____________

Apprentice Applicant Name (PRINT CLEARLY): ___________________________________________

Affidavit: I hereby affirm that I have completed the Report of Apprenticeship

Experience (“Application”); that I have read and understand the complete Application;

and that I declare under penalty of perjury, that all of the information, documents, and

materials submitted in response thereto are true, correct, and complete. I understand

that falsification or misrepresentation of any item or response in this duly-made

application (as defined in 21 NCAC 22A) shall constitute a sufficient basis for the Board

to deny the Application, revoke my license or initiate and pursue any other disciplinary

action including revoking my license after issuance. I attest that I have read and

understand the rules promulgated by the NC State Hearing Aid Dealers and Fitters

Board, codified as Title 21, Chapter 22 of the North Carolina Administrative Code and

North Carolina General Statute Chapter 93D, and I agree to abide by the same.

Apprentice’s Signature:

Sponsor’s Signature:

___________________________________(seal)

__________________________________ (seal)

STATE OF NORTH CAROLINA

COUNTY OF ______________________

Sworn to and subscribed before me this the

_______day of _______________ , 20____

________________________________

Notary Public

________________________________

Notary Printed Name

My Commission Expires: ____________

FOR BOARD USE ONLY:

F3E _________

Cert. _________________

F3-RAE (Updated Oct. 2012)

Report Of Apprenticeship Experience (F3-Rae) Apprentice And Sponsor Affidavits