Full Text
REGISTRATION AFFIDAVIT This form must be signed and notarized for each owner. A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS SUFFICIENT CAUSE FOR DENIAL OF REGISTRATION, REVOCATION OF A PRIOR APPROVAL, INITIATION OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR ENTITY MAKING THE FALSE STATEMENT TO CIVIL AND CRIMINAL PENALTIES AVAILABLE PURSUANT TO APPLICABLE FEDERAL AND STATE LAW. I name printed), swear or affirm under penalty of law that I am of (firm name) and that I have read and understood all of the questions in this application and that all of the foregoing information and statements submitted in this application and its attachment and supporting documents are true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material information. The responses include all material information necessary to fully and accurately identify and explain the operations, capabilities, and pertinent history of the named firm as well as the ownership, control, and affiliations thereof. I recognize that the information submitted in this application is for the purpose of inducing registration approval by Augusta- Richmond County. I understand that Augusta-Richmond County may, by means it deems appropriate, determine the accuracy and truth of the statements in the application, and I authorize the DBE Department to contact any entity named in the application, and the named firm’s bonding companies, banking institutions, credit agencies, contractors, clients, and other certifying agencies for the purpose of verifying the information supplied and determining the named firm’s eligibility. I further certify name) gross revenue does not exceed $500,000, my principal office is located in Augusta-Richmond County and the business owner(s) personal net worth is less than $750,000. I declare, under penalty of perjury, that the information provided in this application and supporting documents relating to my business status and me is true and correct. Signature: Date: NOTARY CERTIFICATE: STATE OF GEORGIA COUNTY OF Sworn to (or affirmed) and subscribed before me this day of 200____ by (Name of person making statement) (Signature of Notary Public-State of Georgia) (Print, Type, or Stamp Commissioned Name of Notary Public) Personally known OR Produced Identification. Type of Identification Produced LSBOP – Registration Application 3/9/08