Dates Attended Eligible Training Program:
Emergency Contact Information
I Understand O.C.G.A. 16-10-71 and Certify My Information
I understand that any material false statement made knowingly and willingly by me on this application, or any documents attached hereto may, in accordance with O.C.G.A. 16-10-71, which provides that upon conviction, a person who knowingly commits the offence of false swearing shall be punished by a fine of not more than $1,000 or by imprisonment for not less than one nor more than five years, or both, subject me to prosecution in a court of law. Additionally, I further understand that any such false statement may subject t me to immediate dismissal from the institution.
Further, I certify that, to the best of my knowledge, the information submitted on this application is true and complete.