Hospital Certificate Of Approval Page 18
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18F-62092 (Rev. 07/08)
Page 18
IX. ATTESTATION
The Management Company CANNOT attest to or sign on behalf of the applicant (Owner).
I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my
knowledge and that knowingly providing false information or omitting information may result in a fine of up to $10,000
or imprisonment not to exceed six years, or both, per Chapter 946.32, Wis. Stats.
Date Signed
-
SIGNATURE
Applicant’s (Owner’s) Legal Representative
Name (Print or type.) - Legal Representative
Title – Legal Representative
RETURN THE COMPLETED APPLICATION TO:
Division of Quality Assurance
Bureau of Technology, Licensing and Education
PO Box 2969
Madison WI 53701-2969
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