Application For Court Appointment Certification Page 10
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10I hereby certify that the facts set forth in the foregoing are true and correct to the best of the
undersigned's knowledge, information and belief and are verified subject to the penalties for unsworn
falsification to authorities under Pennsylvania Crimes Code §4904 (18 Pa. C.S. §4904).
______________________________
Signature
______________________________
Print Name
Date:__________________________
If you would like to be contacted by the Criminal Justice Section of the Philadelphia Bar
Association regarding resources available to criminal defense lawyers, please indicate below:
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Yes, by email at ______________________
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Yes, by phone at ______________________
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Yes, by regular mail at my office address
______________________
______________________
______________________
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No
Revised 1/20/12
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