Application - Medical Corporation

Certification

• I am a shareholder of the Medical Corporation in question.
• I have carefully read the questions in this application and have answered them completely. All of my answers and statements made herein are true and correct.
• I understand that any authorization registered on the basis of this application is based upon the truthfulness and completeness of the statements I have made herein.
• I understand and agree that if any of my answers or other information provided in this application changes, I have a duty to notify the Board and to amend and/or supplement my application immediately.