Figure: 1 TAC §93.33(a)(1)

State of _________________
County of _______________

_______________, personally appeared before me, and being first duly sworn declared that he/she signed this application in the capacity designated, if any, and further states that he/she has read the above application and the statements therein contained are true and correct.

__________________________________________
(Personalized Seal)      Signature of Officer
                                   Authorized to Administer Oaths