_______________________________________________________________________
Organization Name:
___________________________________________________________
Organization Address:
___________________________________________________________
Telephone Number: ___________________________________________________________
Professional License and/or Association Number(s):_________________________
This letter of attestation is being provided on behalf of the following entity:
CA Owner Organization’s Name:
________________________________________________________________
CA Owner Organization’s Address:
________________________________________________________________
CA Owner Organization’s Telephone Number:
________________________________________________________________
I attest that:
Under penalties of perjury, I declare to the best of my knowledge and belief, that the information I have provided is true, correct, and complete.
Signature: ___________________________________ Date: ____________________
Notary Signature: _____________________________ Date: ____________________
Appendix III – Entry/Exit Log
________________________________________________________________
CA Owner Organization’s Address:
________________________________________________________________
CA Owner Organization’s Telephone Number:
________________________________________________________________