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Certification Form - District Of Columbia
| Certification Form Form. This is a District Of Columbia form and can be used in Pharmaceutical Control Health And Licensing Administration Statewide . |
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GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Health Regulations and Licensing Administration Pharmaceutical Control CERTIFICATION FORM TO THE APPLICANT: Please read carefully and completely before signing. A false statement on this certification requires that the Department proceed immediately to revoke the license or permit for which you are not applying and fine LICENSE et seq.) I, PRINT NAME CLEARLY May 11, 1996, D.C. Law 11-118, D.C. Code §47-2861 , certify that as of DATE , I do not owe more than $100.00 to the District of Columbia government as a result of: 1. Fines, penalties or interest assessed pursuant to the Litter Control Administration Action of 1985, effective March 25, 1986 (D.C. Code § 6-2901 et seq.); 2. Fines, penalties or interest assessed pursuant to the Illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (D.C. Law 10-117; D.C. Code § 6-2911 et seq.); 3. Fines, penalties or interest assessed pursuant to the Department of Consumer and Regulatory Affair Civil Infractions Act of 1985, effective October 5, 1986 (D.C. Law 6-42; D.C. Code § 62701 et seq.); or 4. Past due taxes. I understand that if I knowingly falsify this Certification, the Department will move to revoke the license or permit for which I am applying, and to fine me $1,000.00. I further understand that the Department may conduct an investigation to ascertain the veracity of this certification. I understand that this Certification is now required as documentation to accompany my application for a license or permit, and that by completing this Certification, I am not guaranteed that my license or permit will be approved. SIGNATURE OF APPLICANT TITLE 899 North Capitol Street, NE 2nd Floor, Washington, D.C. 20002 (202) 724-4900 Fax: (202) 727-8471 110225cs_certification_cleanhands.docx Rev 2/11 American LegalNet, Inc. www.FormsWorkFlow.com
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