§200.ILLUSTRATION G. Certification Page

I certify under penalty of law that I have read this notification and the exhibits attached hereto and incorporated herein by reference, and know the contents thereof and that the statements therein are true and correct.

 

Executed at		,	Illinois		,		.
(SEAL)
			(Signature(s) of Franchisor, Subfranchisor or Broker)
			By
			Title

 

STATE OF				)	SS
				)
COUNTY OF				)

 

Personally appeared before me this

day of,

the above-named

(and)

to me known to be the

person(s) who executed the foregoing notification (as

and

respectively, of the above-named applicant) and (each) being

first duly sworn, stated upon oath that said notification, and all exhibits submitted herewith, are true and correct.

(Notarial Seal)

Notary

 

(Source:  Amended at 23 Ill. Reg. 11561, effective September 7, 1999)