Notary Public State of: Registration No. FOR STATE USE ONLY OGS APPROVAL: OSC APPROVAL: Approved______ Approved as amended______ Approved______ Disapproved______ Disapproved______ Name:___________________________________________ Name:___________________________________________ Title:____________________________________________ Title:____________________________________________ Date:___________________ Date:___________________
Notary Public Registration No. State of: FOR STATE USE ONLY OGS APPROVAL: Approved______ Approved as amended______ Disapproved______ Name:___________________________________________ Title:____________________________________________ Date:___________________ OSC APPROVAL: Approved______ Disapproved______ Name:___________________________________________ Title:____________________________________________ Date:___________________