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srArE oF_... ...c.kh'.
couNrY oF . . .. gi!fufs;dl
t,. . . . .L-g.t4.tj.. X.- .NG.1UF-1 .-, being duly sworn, depose and say I have read the
foregoing application and know the contents thereof; that the statements contained herein are true and correct andcontain a full and true account of the infc,rration requested; thai I executed this statement with the knowledge thatmisrepresentation or failure to reveal information requested may be deemed sufficient case for denial or revocation ofa wholesaler llcense, that I am voluntarily submitting this application with full knowledge that Nevada Revised Statutes639.210 (10) provides denial or revocation of the appiication of any person for a certificate, license, registration orperrnit if the holder or applicant "Has obtained any certificaie, certification, license or permit by the filing of anapplication, or any recorci, affidavit or other infornration in support thereof, which is false of fraudulent," and further, thatI have famillarlzed myself with the contents of Nevada Statutes on Pharmacists and Wholesaler and the ControlledSubsiances Act as anrended, and the Regulations of the Ne'vaCa State Board of Wholesaler as promulgatedthereunder and agree, if licensed, to ebide thereby,I hereby erpressly waive, reiease and forever dischar'ge the Siate of Nevada, the licensing agency and itsagents f rom any and all manner of action and causes of action whatsoever which l, my administrators or executorscan. shall or may have against the State of Nevacia, the licensing agency and its agents, as a result of my applying tobe a designated representative for a pha,.nacy or whclesaler in the State of Nevada.
Subscribed anc! Slnrcrn tc before me this--.-...- day of
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Notai'y Public
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Signature of Applicant
Ap pr icant's initiat ..(P-.. -
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