DEBRA A. VALENTINE General Counsel
CONNIE WAGNER SARAH L. KNAPP JAMES A. PRUNTY
Federal Trade Commission 601 Pennsylvania Ave., N.W., Rm.
4302 Washington, D.C. 20580 (202) 326-3309 (voice) (202) 326-2558
(facsimile)
BLAINE T. WELSH Assistant United States Attorney 701 E.
Bridger Ave., Ste. 800 Las Vegas, NV 89101 (702)
388-6336
Attorneys for Plaintiff
UNITED STATES DISTRICT COURT DISTRICT OF
NEVADA
FEDERAL TRADE COMMISSION,
Plaintiff v. SANDRA L. RENNERT, PHILIP RENNERT, LYLE
MORTENSEN, INTERNATIONAL OUTSOURCING GROUP, INC., FOCUS MEDICAL GROUP,
INC., TRIMLINE, INC., AFFORDABLE ACCENTS, INC., WORLD WIDE RX, INC., WORLD
WIDE MEDICINE, INC., PSRENN, INC. and DOCTORS A.S.A.P., INC.,
Defendants.
CIVIL ACTION No.
STIPULATED FINAL ORDER FOR PERMANENT
INJUNCTION AS TO SANDRA L. AND PHILIP RENNERT AND
CORPORATE DEFENDANTS
Plaintiff, the Federal Trade Commission ("FTC" or "Commission"), has
filed a Complaint for permanent injunction and other relief against Sandra
Rennert, Philip Rennert, Lyle Mortensen, International Outsourcing Group,
Inc., Focus Medical Group, Inc., Trimline., Inc., Affordable Accents,
Inc., World Wide RX, Inc., World Wide Medicine, Inc., PSRenn, Inc. and
Doctors A.S.A.P., Inc. (collectively "defendants") pursuant to Section
13(b) of the Federal Trade Commission Act ("FTC Act"), 15 U.S.C.
§ 53(b). Defendant Lyle Mortensen is not a party to this Order.
The Commission and defendants have stipulated to the entry of the
following Stipulated Final Order for Permanent Injunction ("Order") in
settlement of the Commission's complaint against defendants. The Court,
being advised in the premises, finds:
FINDINGS
1. This Court has jurisdiction of the subject matter and of the
parties;
2. The Complaint states a claim upon which relief may be granted under
Sections 5(a) 12, and 13(b) of the Federal Trade Commission Act, 15 U.S.C.
§§ 45(a) and 53(b);
3. Venue is proper as to all parties in the District of Nevada;
4. The activities of defendants are in or affecting commerce, as
defined in the FTC Act, 15 U.S.C. § 44;
5. This agreement is for settlement purposes only and does not
constitute an admission by defendants that, as alleged in the complaint,
the law has been violated, or that the facts in the complaint, other than
the jurisdictional facts, are true.
6. Defendants have waived all rights that may arise under the Equal
Access to Justice Act, 28 U.S.C. § 2412, amended by Pub.
L. 104-121, 110 Stat. 847, 863-64 (1996);
7. This action and the relief awarded herein are in addition to, and
not in lieu of, other remedies as may be provided by law;
8. Each party shall bear its own costs and attorneys' fees; and
9. Entry of this Order is in the public interest.
DEFINITIONS
1. "Defendants" shall mean Sandra Rennert, Philip Rennert,
International Outsourcing Group, Inc., Focus Medical Group, Inc.,
Trimline., Inc., Affordable Accents, Inc., World Wide RX, Inc., World Wide
Medicine, Inc., PSRenn, Inc. and Doctors A.S.A.P., Inc..
2. "Individual Defendants" shall mean Sandra Rennert and Philip
Rennert.
3. "Corporate Defendants" shall mean International Outsourcing Group,
Inc., Focus Medical Group, Inc., Trimline., Inc., Affordable Accents,
Inc., World Wide RX, Inc., World Wide Medicine, Inc., PSRenn, Inc. and
Doctors A.S.A.P., Inc., their divisions and subsidiaries, successors and
assigns, and their officers, agents, representatives and employees.
4. "Employment" shall include any affiliation (paid or unpaid) with any
business, non-profit, or government entity, including the performance of
services as an officer, owner, manager, supervisor, employee, consultant,
or independent contractor; and "Employer" shall mean any and all
individuals or entities for whom any defendant performs services as an
employee, consultant, or independent contractor.
5. "Disclosure" or "disclosed to third party (ies)" shall mean (a) the
release of personal information to any other individual, firm, or
organization for any purpose not necessary to maintain the technical
functioning of a Web site or online service, or to fulfill a consumer's
request, or (b) making publicly available such information by any means
including public posting on or through home pages, email services, message
boards, or chat rooms.
6. "Personal information" means individually identifiable information
about an individual collected online including: (a) a first and last name,
(b) a home or other physical address including street name and name of
city or town, (c) an email address or other online contact information,
including an instant messaging user identifier or a screen name that
reveals an individual's email address, (d) a telephone number, (e) a
social security number, (f) a persistent identifier, such as a customer
number held in a cookie or a processor serial number, where such
identifier is associated with other individually identifiable information,
(g) a combination of a last name or photograph of the individual with
other information such that the combination permits physical or online
contacting, and (h) information concerning a Web site user that the
operator collects online from the user, including medical information or a
prescription, that is combined with an identifier described in this
definition.
7. "Clearly and conspicuously" means of a size, shade, appearing on the
screen for a duration and in a location, sufficient for an ordinary
consumer to read and understand it.
8. A requirement that any defendant "notify the Commission" shall mean
that the defendant shall send the necessary information via first-class
mail, costs prepaid, to the Associate Director for Enforcement, Federal
Trade Commission, 600 Pennsylvania Ave., N.W., Washington, D.C. 20580.
Attn: FTC v. Rennert, et al. (D. NV).
9. The term "includes" or "including" in this Order shall mean "without
limitation."
10. The terms "and" and "or" in this Order shall be construed
conjunctively or disjunctively as necessary, to make the applicable phrase
or sentence inclusive rather than exclusive.
ORDER
I. PROHIBITED INTERNET BUSINESS
PRACTICES
IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that
defendants, and their officers, agents, servants, employees and attorneys,
and all other persons in active concert or participation with them who
receive actual notice of this Order by personal service or otherwise,
shall not advertise, promote, offer to sell or sell prescription drugs
over the Internet unless they disclose, clearly and conspicuously:
- A. the name, business address, and phone number of the pharmacy that
will dispense the prescription drug, and the state or states where such
pharmacy is licensed or registered to do business;
- B. the name, address and phone number of the physician who will
review the information provided by the consumer for the purpose of
determining whether to issue or authorize the prescription, if such
service is offered, and the state or states where the physician is
licensed or authorized to practice medicine;
- C. the name, business address, phone number and a contact person for
the entity offering the prescription drugs;
- D. the state or states from which the entity will accept orders for
prescription drugs; and
- E. that "Dispensing a prescription drug without a valid prescription
is a violation of Federal law. More information on purchasing
prescription drugs online is available at www.fda.gov."
IT IS FURTHER ORDERED that defendants, and their
officers, agents, servants, employees and attorneys, and all other persons
in active concert or participation with them who receive actual notice of
this Order by personal service or otherwise are hereby permanently
restrained and enjoined from misrepresenting, expressly or by implication:
- A. In connection with the advertisement, promotion, offering for
sale or sale of prescription drugs over the Internet
- 1. that prescriptions are filled or dispensed by a pharmacy owned
and operated by defendants;
- 2. that prescription requests are taken, reviewed, filled or
dispensed by a medical clinic;
- 3. that prescription requests are taken, reviewed, filled or
dispensed by resident medical personnel;
- 4. that defendants offer medical consultations performed by a
network of physicians; or
- 5. that defendants operate a medical clinic with an on-site
pharmacy; and
- B. In connection with the advertisement, promotion, offering for
sale or sale of any goods or services over the Internet
- 1. that personal or financial information supplied by a consumer
will be used only to provide that consumer with requested goods or
services; or
- 2. any other material fact about the scope or nature of
defendants' goods, services or facilities.
II. PROHIBITED CREDIT CARD BILLING
PRACTICES
IT IS FURTHER ORDERED that defendants, and their
officers, agents, servants, employees and attorneys, and all other persons
in active concert or participation with them who receive actual notice of
this Order by personal service or otherwise, in connection with credit
card or debit card billing or collections are hereby permanently
restrained and enjoined from:
- A. Misrepresenting, expressly or by implication, that personal or
financial information supplied by a consumer will be used only to
provide that consumer with requested goods or services;
- B. Representing, expressly or by implication, that a consumer is
liable for the cost of any goods or services that the consumer did not
order; and
- C. Processing any charge to a consumer's credit or debit card that
the consumer has not expressly authorized.
III. PROHIBITED DISCLOSURE OF PERSONAL
INFORMATION
IT IS FURTHER ORDERED that defendants, and their
officers, agents, servants, employees and attorneys, and all other persons
in active concert or participation with them who receive actual notice of
this Order by personal service or otherwise, are hereby permanently
restrained and enjoined from
- A. Selling, renting, leasing, transferring or otherwise disclosing
to any third party(ies) personal information that was collected from any
consumer before defendants posted privacy notice(s) in compliance with
Paragraph V.
- B. Selling, renting, leasing, transferring or otherwise disclosing
to any third party(ies) personal information that was collected from any
consumer after defendants posted privacy notice(s) in compliance with
Paragraph V, unless the consumer expressly authorizes the
disclosure in advance of any disclosure.
Provided that defendants may provide such information to law
enforcement authorities or as required to do so by any law, regulation or
court order, including as required by this Order.
IV. WEB SITE OPERATION REQUIREMENTS
IT IS FURTHER ORDERED that defendants, and their
officers, agents, servants, employees and attorneys, and all other persons
in active concert or participation with them who receive actual notice of
this Order by personal service or otherwise, in connection with the
advertising, promotion, offering for sale or sale of prescription drugs
over the Internet shall:
- A. Establish and maintain reasonable procedures to protect the
confidentiality, security and integrity of personal information
collected from consumers;
- B. Provide reasonable means by which a consumer may access and
review personal information concerning him or her; and
- C. Provide reasonable means by which a consumer may modify
inaccurate personal information or delete personal information,
concerning him or her.
V. PRIVACY NOTICE
IT IS FURTHER ORDERED that defendants, and
their officers, agents, servants, employees and attorneys, and all other
persons in active concert or participation with them who receive actual
notice of this Order by personal service or otherwise, in connection with
the advertising, promotion, or offering of goods or services over the
Internet, shall provide notice to consumers of its practices with regard
to its collection and use of personal information ("Privacy Notice").
- A. The Privacy Notice shall disclose the following:
- 1. The types of personal information ("PI") that are obtained by
means of a Web site, email message, message board, chat room, or any
other means. The disclosure shall extend, without limitation, to (a)
PI that is actively obtained (including name, geographic address,
email address, age, medical information, and financial information),
and (b) PI that is passively obtained (including clickstream
information, any information from a cookie file, and any persistent or
globally unique identifier);
- 2. The uses that will be made of PI, and the extent to which the
consumer may control such uses. The required disclosure of the uses
that will be made of PI shall include (a) the purpose(s) for which
defendants will use the PI (such as to fill an order, or to convey
marketing messages) and (b) identification, by name or by type of
entity, of any third parties to which PI may be disclosed (such as
business partners, online advertising service providers, Web-site
advertisers, list brokers, and the general public) in accordance with
Paragraph III of the Order;
- 3. The means by which a consumer may access and review PI
concerning him or her;
- 4. The means by which a consumer may modify or delete PI
concerning him or her; and
- 5. What measures are employed to ensure the security of the PI.
- B. The Privacy Notice shall be phrased in terms that are clear,
concise, well-organized, and easily understandable by an average
consumer. The Privacy Notice shall not include extraneous information
that distracts the reader from the required disclosures.
- C. In the case of a site on the World Wide Web, the Privacy Notice
shall appear on the home page, and at each location on the site at which
PI is collected; provided, that defendants may comply with this
provision by (1) placing a clear and conspicuous hyperlink labeled
"Privacy Notice" on the home page of the Web site, which shall link
directly to a Privacy Notice as described in this Part, and (2) placing,
at each location on the site at which PI is collected, the following
statement, clearly and conspicuously, in bold typeface: "NOTICE:
We collect personal information on this site. To learn more about how we
use your information, see our Privacy Notice." The words
"Privacy Notice" described in subparagraph (2) shall
link directly to a Privacy Notice as described in this Part.
- D. In the case of a message soliciting the submission of PI that is
transmitted via email, a message board, a chat service, or any other
means, the Privacy Notice shall appear in such message;
provided, that defendants may comply with this provision by
including within the message the following statement, clearly and
conspicuously, in bold typeface: "Before providing personal
information to us you should read our Privacy Notice." The
words "Privacy Notice" shall link directly to a Privacy
Notice, as described in this Part, that is maintained on a Web site.
VI. ALLEGATIONS IN THE COMPLAINT
IT IS FURTHER ORDERED THAT the facts as alleged in the
Complaint filed with this Judgment shall be taken as true solely for the
purpose of any subsequent litigation filed by the FTC to enforce its
rights under this Judgment.
VII. ORDER DISTRIBUTION
IT IS FURTHER ORDERED THAT, for a period of five (5)
years from the date of entry of this Judgment, defendants shall:
- A. Provide a copy of this Judgment to, and obtain a signed and dated
acknowledgment of receipt of same from each officer or director, each
individual serving in a management capacity, any employee of the
corporate defendants responsible for billing credit or debit cards or
engaged in the offer or sale of prescription medications over the
Internet and all individuals or entities engaged in marketing on behalf
of defendants including but not limited to, consultants or independent
contractors immediately upon employing, contracting with or retaining
any such persons, for any business where:
- 1. Any defendant is the majority owner of the business or directly
or indirectly manages or controls the business, and
- 2. The business is engaged in the advertising, promotion, or sale
of goods or services over the Internet or any other commercial venture
where consumers' credit or debit cards are billed for products or
services.
- B. Maintain for a period of five (5) years after execution, and upon
reasonable notice, make available to representatives of the Commission,
the original signed and dated acknowledgments of the receipt of copies
of this Order, as required in Subsection A of this Paragraph.
VIII. RECORD KEEPING
IT IS FURTHER ORDERED THAT for a period of five (5)
years from the date of entry of this Judgment, defendants shall create and
maintain:
- A. Records sufficient to demonstrate compliance with the provisions
of this Judgment, including:
- 1. All advertisements and promotional materials for any product or
service offered for sale over the Internet by defendants, including
the following information for any advertising displayed or accessible
as a Web page on the Internet or in a similar format on a commercial
online service:
- a) a printout of all screens or pages displayed or accessible
online;
- b) the date the information was initially placed online;
- c) if applicable, the date the information ceased to be
available online;
- d) a transcript of any audio or video clips contained in the
screens or pages, and identification of any audio, video, or other
programs necessary to hear or view the clips; and
- e) the name, mailing address and phone number of any entity with
whom defendants arranged for the placement of the information online
(i.e., the owner of the Internet domain name(s) and, if different,
the owner of the server(s) through which the Web page is made
accessible on the Internet.)
- 2. All electronic mail sent to consumers by any corporate
defendant, or by any individual defendant on behalf of any corporate
defendant.
- B. Records accurately reflecting: the name, address, and home
telephone number of each person employed in any capacity by any
defendant, including independent contractors; the person's job title or
position; the date upon which the person commenced work; and if
applicable, the date and reason for the person's termination.
- C. Records containing the following information for each consumer
whose credit or debit card defendants bill for any goods or services,
including prescription medications, either directly or through any third
party:
- 1. the consumer's name, address and telephone number;
- 2. documentation of charge; and
- 3. the name, address and telephone number of the billing agent, if
applicable.
- D. Books, records, and accounts that, in reasonable detail,
accurately and fairly reflect the cost of goods or services sold, annual
and quarterly gross revenues generated, and the disbursement of such
revenues; and
- E. Records of every consumer complaint or refund request received by
defendants, whether directly, or indirectly through a third party.
IX. ACCESS TO BUSINESS PREMISES
IT IS FURTHER ORDERED THAT, for a period of five (5)
years from the date of entry of this Judgment, for the purpose of further
determining compliance with this Judgment, defendants shall permit
representatives of the Commission, within 5 business days of receipt of
written notice from the Commission:
- A. Access during normal business hours to any office, or facility
storing documents, of any business where:
- 1. Any defendant is the majority owner of the business or directly
or indirectly manages or controls the business, and
- 2. The business is engaged in the advertising, promotion, offering
for sale or fulfillment services for goods or services sold over the
Internet or any other commercial venture where consumers' credit or
debit cards are billed for products or services.
- In providing such access, defendants shall permit representatives of
the Commission to inspect and copy all documents relevant to the subject
of this proceeding; and shall permit Commission representatives to
remove documents relevant to any matter contained in this Judgment for a
period not to exceed 5 business days so that the documents may be
inspected, inventoried, and copied; and
- B. To interview officers, directors, and employees, including all
personnel involved in responding to consumer complaints or inquiries,
and all sales personnel, whether designated as employees, consultants,
independent contractors or otherwise, of any business to which
Subsection A of this Paragraph applies, concerning matters relevant to
the subject of this proceeding. The person interviewed may have counsel
present; provided that, upon application of the Commission and
for good cause shown, the Court may enter an ex parte order
granting immediate access to defendants' business premises for the
purposes of inspecting and copying all documents relevant to any matter
contained in this Judgment.
X. MONITORING OF INDIVIDUAL
DEFENDANTS
IT IS FURTHER ORDERED THAT for a period of five (5)
years from the date of entry of this Judgment, each individual defendant
shall inform the Commission by written notification within 30 days of:
- A. Any change in the individual defendant's residential address,
occupation, place of business, or place of employment;
- B. Any change in the name, address, type of business, or identity of
each company, corporation, partnership, or business owned or controlled
directly or indirectly by the individual defendant;
- C. Any proposed change in any company, corporation, partnership, or
business that is owned or controlled, directly or indirectly, by the
individual defendant including: dissolution, assignment, or sale
resulting in the emergence of a successor corporation, the creation or
dissolution of subsidiaries, or any other change in their business
relationship(s) that may affect compliance obligations arising out of
this Judgment;
- D. Any affiliation with a new business or employment involving the
advertising, promotion, offering for sale or fulfillment services for
prescription medications sold over the Internet or the billing of
consumers' credit or debit cards, including a description of such
business, the business address, as well as the individual defendant's
interest in and duties in connection with such business or employment;
- E. The formation of any corporation, sole proprietorship,
partnership, or independent consulting business or any other business
entity that advertises, promotes, sells or provides fulfillment services
for prescription medications offered over the Internet, or the billing
of consumers' credit or debit cards, in which the individual defendant
is an officer or director, or in which (s)he holds 10% or more of the
stock; and
- F. Any termination or suspension of business operations by the
individual defendant, the resumption of business operations, or any
termination, suspension or establishment of any type of consulting
relationship with any third party relating to the advertising,
promotion, sale or fulfillment of prescription medications offered over
the Internet.
XI. NOTIFICATION OF CHANGES IN BUSINESS
STRUCTURE
IT IS FURTHER ORDERED THAT for a period of five (5)
years, each corporate defendant, its successors and assigns, shall notify
the Commission at least 30 days prior to any change in the business
including: any merger, incorporation, dissolution, assignment, sale
resulting in the emergence of a successor corporation, the creation or
dissolution of a subsidiary or parent, or any other change that may affect
defendant's obligations under this Order.
XII. COMPLIANCE REPORTING BY
DEFENDANTS
IT IS FURTHER ORDERED THAT 180 days after the date of
entry of this Order, each defendant shall provide a written report to the
FTC, sworn to under penalty of perjury, setting forth in detail the manner
and form in which that defendant has complied and is complying with this
Judgment. This report shall include:
- A. The then current residence address and telephone number of any
individual defendant and chief executive officer of a corporate
defendant;
- B. The then current business or employment address and telephone
number of any employer of any individual defendant; a description of the
business activities of each employer, and defendant's title and
responsibilities for each employer;
- C. A copy of each acknowledgment of receipt of this Judgment
obtained by defendants pursuant to Paragraph VII; and
- D. A statement describing the manner in which defendants have
complied and are complying with Paragraphs I, II, III, IV, V, VII and
VIII of this Judgment.
Upon written request by a representative of the Commission, defendants
shall submit additional written reports (under oath, if requested) and
produce documents on 15 days' notice with respect to any conduct subject
to this Judgment. For purposes of the compliance reporting required by
this Paragraph, the Commission is authorized to communicate in writing
directly with defendants.
XIII. COMMISSION'S AUTHORITY TO MONITOR
COMPLIANCE
IT IS FURTHER ORDERED THAT the Commission is
authorized to monitor defendants' compliance with this Judgment by all
lawful means, including but not limited to the following means:
- A. The Commission is authorized, without further leave of court, to
obtain discovery from any person in the manner provided by Chapter V of
the Federal Rules of Civil Procedure, Fed. R. Civ. P. 26 - 37, including
by use of compulsory process pursuant to Fed. R. Civ. P. 45, for the
purpose of monitoring and investigating defendants' compliance with any
provision of this Judgment;
- B. The Commission is authorized to use representatives posing as
consumers and suppliers to defendants, defendants' employees, or any
other entity managed or controlled in whole or in part by defendants,
without the necessity of identification or prior notice;
Nothing in this Judgment shall limit the Commission's lawful use of
compulsory process, pursuant to Sections 9 and 20 of the FTC Act, 15
U.S.C. §§ 49, 57b-1, to investigate whether defendants have violated any
provision of this Judgment or Section 5 of the FTC Act, 15 U.S.C. §
45.
XIV. ACKNOWLEDGMENT OF RECEIPT OF ORDER BY
DEFENDANTS
IT IS FURTHER ORDERED THAT, within 5 business days
after receipt by defendants of this Order as entered by the Court,
defendants Philip Rennert, individually, and defendant Sandra Rennert
individually and on behalf of the corporate defendants, shall each submit
to the Commission a truthful sworn statement, in the form shown on
Appendix A, that shall acknowledge receipt of this Judgment.
XV. CONTINUING JURISDICTION
IT IS HEREBY ORDERED THAT this Court shall retain
jurisdiction of this matter for purposes of construction, modification,
and enforcement of this Judgment.
The parties hereby consent to the terms and conditions set forth above
and consent to
entry of the Final Judgment without further notice to the parties. Each
party to this Judgment hereby agrees to bear its own costs and attorneys
fees incurred in connection with this action.
STIPULATED AND AGREED TO BY:
FOR THE PLAINTIFF |
FOR THE DEFENDANTS |
__________________________ Connie
Wagner James A. Prunty Sarah L. Knapp Federal Trade
Commission Washington, DC 20580 |
__________________________ Sandra
Rennert, Individually and on behalf of:
International Outsourcing Group, Inc., Focus Medical Group.
Inc., Trimline, Inc., Affordable Accents, Inc., World Wide RX.
Inc., World Wide Medicine, Inc., PSRenn, Inc., and
Doctors A.S.A.P., Inc.
__________________________ Philip
Rennert Individually |
IT IS SO ORDERED, this ______ day of __________, 2000
in ______________, Nevada.
_______________________________________ UNITED STATES DISTRICT
JUDGE
UNITED STATES DISTRICT COURT DISTRICT OF
NEVADA
FEDERAL TRADE COMMISSION,
Plaintiff v. SANDRA L. RENNERT, PHILIP RENNERT, LYLE
MORTENSEN, INTERNATIONAL OUTSOURCING GROUP, INC., FOCUS MEDICAL GROUP,
INC., TRIMLINE, INC., AFFORDABLE ACCENTS, INC., WORLD WIDE RX, INC., WORLD
WIDE MEDICINE, INC., PSRENN, INC. and DOCTORS A.S.A.P., INC.,
Defendants.
AFFIDAVIT OF [DEFENDANT]
[Defendant], being duly sworn, hereby states and affirms:
1. My name is . I am a citizen of the United States and am over the age
of eighteen. I have personal knowledge of the matters discussed in this
declaration, and if called as a witness, I could and would competently
testify as to the matters stated herein. I am a defendant in the above
captioned action.
2. On (date) , I received a copy of the Stipulated Final Order for
Permanent Injunction, entered on _______ in the United States District
Court for the District of Nevada. A true and correct copy of the Order
that I received is appended to this Affidavit.
I hereby declare under penalty of perjury under the laws of the United
States of America that the foregoing is true and correct. Executed on
(date) , at (city, state) ,
(Name of Defendant)
STATE OF
COUNTY OF
BEFORE ME this day personally appeared , who being first duly sworn,
deposes and says that s/he has read and understands the foregoing
statement and that s/he has executed the same for the purposes contained
therein.
SUBSCRIBED AND SWORN TO before me this day of , 2000, by . S/he is
personally known to me or has presented (state identification) as
identification.
Print Name
NOTARY PUBLIC,
STATE OF
Commission Number
Affix Seal |