DENTAL ASSISTING PROGRAM

Hello:

Congratulations on your acceptance in the Foothill College Dental Assisting Program. You have been selected for early admittance. I am enclosing a package of documents. Please review and complete any requirements before the due date.

Send the documents to:

Cara Miyasaki Foothill College Dental Assisting Program 12345 El Monte Road Los Altos Hills, CA 94022

Before school starts you will need to:

1. Apply for admission to Foothill College and get a Campus Wide Identification (CWID) number at thisURL: https://foothill.edu/reg/

2. Complete the enclosed Statement of Acceptance and Registration Agreement for Fall quarter classesand return in the stamped self-addressed envelope within 10 days of receiving this letter.

• The Admissions office will automatically enroll you in your Fall quarter classes and I will notifyyou to pay your registration fees.

• Students currently receiving financial aid from the college will get notices that they need topay but will not be automatically dropped for non-payment. Ignore the payment notices butpay registration fees upon receiving your financial aid.

3. Get a physical exam and make sure all vaccinations are current.4. Register for a Basic Life Support Certification class from the American Heart Association.5. Purchase your uniform, jacket, and protective clothing (cloth gown) – Wear uniform first day of school6. Wait for email instructions in June/July on how to purchase the Fall dental assisting kit.

Please email me or call me if you have any questions. Congratulations again!

Sincerely,

Cara Miyasaki, CDA, RDA, RDHEF, MS Program Director miyasakicara@fhda.edu (650) 949-7351

TABLE OF CONTENTS

Due Date Page Statement of acceptance Within 10 days of

receiving packet 3

Fall registration instructions Within 10 days of receiving packet

4 Physical examination forms 5 Basic life support certification (CPR) 9 Background check 10 Fall dental assisting kit payment information To be notified 13 Dental assisting uniform policy First day of

school 14

Dental assisting sample schedule XXXXXXXX 15 Dental assisting program application

• Please feel free to give this to anyonewho may be interested in the program

XXXXXXXXX 16

To be notified

To be notifiedTo be notified

DENTAL ASSISTING PROGRAM STATEMENT OF ACCEPTANCE

(Due within 10 days of receiving this acceptance packet)

Cara Miyasaki Dental Assisting Program Applications Foothill College 12345 El Monte Road Los Altos Hills, CA 94022

We have received your dental assisting application for Foothill College and you have been provisionally accepted pending receipt of required information. To secure your provisional acceptance in the Dental Assisting program, complete and return this statement of acceptance to the above address within 10 days.

I accept my position as a student in the Foothill College Dental Assisting Program for the class starting in September 2019.

I do not accept my position as a student in the Foothill College Dental Assisting Program for the class starting September 2019.

Today’s Date: _______________________________

Street Address: ______________________________

City, State, Zip: ______________________________

Home Phone: ____________________________

Cell Phone:

Please use the following upper case letter format when filling in your email address below:

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Ø 1 2 3 4 5 6 7 8 9

*Valid & Current Email Address:

*It’s very important that you have a valid email address that you check often, as all futurecorrespondence will be via email; and some of this information will be time-sensitive. When listing your email address above, please use ALL CAPS, and distinguish between a zero Ø, and the letter “O”; so we can be sure the important information you need, will reach you.

Student's Signature

Last First Middle Initial

Please print full name above clearly.

FALL REGISTRATION INSTRUCTIONSDue within 10 days of receiving this acceptance packet

Registration for your Fall classes confirms your acceptance in the dental assisting program. Complete this form, sign and send back with the enclosed envelope.

Once received, you will be automatically registered in June 2019 by the admissions office for your Fall quarter dental assisting classes. You will be notified when officially enrolled in Fall 2019 classes.

If you are signed up with financial aid and will be receiving aid from the college, you will receive notices that you need to pay for your registration. If the college knows you are getting financial aid, you will not be automatically dropped for non-payment. You can either pay for your registration fees upon registration and get reimbursement from your financial aid award or you can ignore the payment notices and pay your registration fees upon receiving your financial aid.

If you need to apply for financial aid but have not done so, you may need to think about deferring your acceptance until next year (September 2020).

Some fees are optional. If you have questions please contact admissions and records cashiers office (650) 949-7331 or foothillcashiersoffice@foothill.edu.

Print Name: ________________________________

Student CWID#____________________________

Fall Quarter Registration

CRN# To be filled in by program director

Course Number

Course Name

DA 50 Orientation to Dental Assisting (online) DA 58 Dental Specialties (online) DA 51A Introduction to Chairside Assisting DA 53A Introduction to Radiology DA 62A Dental Sciences DA 71 Infection Control & Hazardous Waste Management

By signing this form and returning it to the dental assisting program, I give my permission for Foothill College to enroll me in the core dental assisting courses for the Fall 2019 quarter.

Signature________________________________ Date_______________

5/24

DENTAL ASSISTING PROGRAM

Dear Applicant,

You are about to enter a health care field. For your own safety, and to comply with requirements for clinical rotations, it is imperative you have a physical examination, all immunizations and proof of immunity completed. Please make an appointment with your physician or the Foothill College Health Center. Physical exams and immunizations can be obtained at low cost at Foothill College Health Center if you do not have your own physician. (Note: Foothill College Health Center will be closed during the summer, July-mid September)

Please see that the following are completed:

1. Applicant/student completes the Student Health Questionnaire Form (page 2), and bringthe entire packet (page 1-4) to see your physician or Foothill College Health Center.

2. Your physician/Foothill College Health Center completes the Health Appraisal Form,Immunizations Form and updates vaccines when necessary.

3. Copies of all immunization and titer records must be attached and returned with theseforms. If Hepatitis B doses are being started, please record the first dose and turn in theform. It is not necessary to delay turning in the forms for the second or third dose of thisvaccine, Health histories that do not indicate dates of immunizations or proof of immunitywill not be accepted.

4. Make a copy of all Health records for your personal file.5. Turn in the original documents to the program director by __________________.

IMPORTANT

Page 1 of 4

FOOTHILL COLLEGE DENTAL ASSISTING PROGRAM STUDENT HEALTH QUESTIONNAIRE FORM

AUTHORIZATION FOR RELEASE OF EXAM and LAB RESULTS

THIS PAGE TO BE COMPLETED BY THE STUDENT

Name (Print) Phone DOB

Address City Zip

Emergency Contact Info: Name Relationship: Phone: _______

Physician Info: Name: ___________________________________ Phone: _______________ City: ______________

Please answer the following questions regarding your health status. This information will facilitate the physician’s completion of the Health Appraisal form, as well as help insure the safety of the student and of patients. Students are not discriminated against due to physical limitation or diseases. Note: students may be required by the clinical facility to meet additional health requirements. The following information is confidential and does not affect entry into the program, unless you are unable to meet the Technical Standards.

1. Do you have a hearing impairment? Yes No *If yes, please explain:

2. Do you have a vision impairment? Yes No *If yes, please explain:

3. Do you have any condition that limitsyour physical mobility?

Yes No *If yes, please explain:

4. Do you have any condition that limitsyour ability to lift?

Yes No *If yes, please explain:

5. Do you have allergies? Yes No *If yes, please explain:

6. Have you experienced fainting spells,dizziness, or convulsions

Yes No *If yes, please explain:

7. Do you smoke? Yes No If yes, how much per day?

8. Are you pregnant? Yes No

9. Are you taking any medication? Yes No *If yes, please list medications and reason for taking.

10. Please list any & all physical, medical, emotional, or psychological conditions you have.

*If you answered “yes” to any of the above questions and need more room, please attach numbered answers on a separate sheet of paper.

Do you have any concerns regarding your health in relation to performance in or completion of this program? Areas of concern should be discussed with the director of the program prior to enrollment.

I have read the above carefully and have answered all questions correctly to the best of my knowledge. I hereby authorize my medical provider to release and disclose all results of my physical, lab results, including lab printouts. This authorization shall be valid until revoked in writing. I have been offered a copy of this signed Authorization form.

By signing this Authorization I hereby RELEASE FROM ALL LIABILITY both the Health Services and the Program for disclosing/acting upon said test results.

Student’s Signature _____________________________________ Date _____________________

Page 2 of 4

FOOTHILL COLLEGE DENTAL ASSISTING PROGRAM HEALTH APPRAISAL FORM

Student’s Name: DOB: Date:

ALL BLANKS AND QUESTIONS MUST BE COMPLETED BY THE MEDICAL EXAM PROFESSIONAL

Height ____________ Weight __________ Blood Pressure _______________ BMI ___________

Check if Negative - otherwise please comment:

Nutrition Teeth: Cavities Posture Malocclusion Skin Tonsils Nasal: Obs. Heart

Disch. Lungs Ears: Right Abdomen

Left Ortho. Eyes: Right Hernia: Right Left Left Lymph Glands Neuro. Extremities Breasts Back

Is there any impairment of vision or hearing for which the school could compensate by proper seating or other action? Yes No

If yes, what do you recommend?

Is there any physical impairment which may limit participation in: (a) Classroom activities. Yes No (b) Clinical experience. Yes No (c) Heavy lifting. Yes No

If yes, what do you recommend?

Is this student subject to any of the following chronic conditions? i.e., epilepsy, fainting, diabetes, allergies, back injuries. Yes No

If yes, what do you recommend?

Do you have knowledge of any emotional, mental or physical condition for which this student should remain under periodic medical observation? Yes No

If yes, what do you recommend?

Does the above named individual exhibit any signs of active communicable diseases? If yes, please explain and include estimated length of communicability and treatment modality.

______

Audiogram Testing Date Results

Titmus eye exam Date Results

Page 3 of 4

Student’s Name: DOB: Date:

Serum blood titer reports: must be drawn within one year of the program start date in September and show immunity against measles, mumps, rubella, varicella and Hepatitis B. Immunization records and/or “had the disease” alone will not be accepted for these diseases. You must submit serum titer lab results that include reference ranges.

The lab results for the following can be either Qualitative (QL) or Quantitative (QN).

Results Comments or Follow up

Measles AB IGG, EIA

Rubella Antibodies, IgG

Mumps Antibodies, IgG

Varicella IgG AB

QuantiFERON TB TEST

Please attach lab results Date ________________ Titer Results __________________ or

2-STEP TB Test: Date Administered _______________ Date Read __________________ Results _____________________

Chest X-Ray: Date Taken _____________________ Results _____________________

Is the student being put on anti-TB drug therapy? Yes No Refused Date of Treatment ___________________

CURRENT TDAP IMMUNIZATION OR BOOSTER Date _______________ Within the last 5 years

HEPATITIS B VACCINE: Date Administered #1_____________ #2_____________ #3_____________ (If Hepatitis B doses are being started, please record the first dose and turn in the form. It is not necessary to delay turning the forms for the second or third dose of this vaccine) AND

Hepatitis B Surface Antibody titer results Date ___________________ Results __________________________________ (6 weeks post HBV immunization) Hepatitis B Antigen (HBsAg) titer results Date ___________________ Results __________________________________

Hepatitis C Antibody (HCsAb) titer results Date ___________________ Results __________________________________

If HCsAb positive, is the student being put on antiviral drug therapy? Yes No Refused

I have examined the above named individual and found no condition, which would present a hazard to him/herself, other employees, residents or visitors.

Physician/Clinician Signature Date

Physician/Clinician Name Phone

Address ____________________________________________ City ___________________ Zip Code ___________

For questions please call or email to Cara Miyasaki 650-949-7351 or miyasakicara@fhda.edu

Page 4 of 4

Basic Life Support (BLS) Due __________________

Students must be BLS-certified by completing the certification requirement with the American Heart Association at http://cpr.heart.org/AHAECC/CPRAndECC/Training/HealthcareProfessional/UCM_473185_Healthcare-Professional.jsp

It is the student's responsibility to accomplish this certification. A copy of the BLS card (front and back) must be submitted to the Director of the Dental Assisting Program.

See below for sample

BACKGROUND CHECK Due __________________

All students are required to get a background check prior to beginning the program. Background checks will be conducted by the Verify Group. Students can either walk-in or make an appointment online at

http://verifygroup.com/schedule/

Verify Group, Inc Contact Info: 262 E Hamilton Ave, Suite A Campbell, CA 95008 Phone: 408-761-2156

Verify Group, Inc hours: Monday-Friday 9:00 am – 5:00 pm Saturday 9:00 am – 12:00 pm

What to bring:

• California ID, Driver License or Passport• Request for Live Scan Service Form-filled it out before appointment

Your background check will be sent to your home address. DO NOT OPEN THE ENVELOPE. Turn in the envelope UNOPENED to the program director.

STATE OF CALIFORNIA DEPARTMENT OF JUSTICEBCIA 8016RR (orig. 04/2001; rev. 10/2014)

REQUEST FOR LIVE SCAN SERVICE (Record Review or Foreign Adoption)

Page 1 of 2

Applicant Submission

ORI (Code assigned by DOJ)Type of Application (Check One Only) Record Review Foreign Adoption

Reason for Application

Contributing Agency Information:

Agency Authorized to Receive Criminal Record Information

Street Address or P.O. Box

City State ZIP Code

Mail Code (five-digit code assigned by DOJ)

Contact Name (mandatory for all school submissions)

Contact Telephone Number

Applicant Information:

Last Name First Name Middle Initial SuffixOther Name (AKA or Alias) Last First Suffix

Date of BirthSex Male Female Driver's License Number

Misc. Number (Other Identification Number)Height Weight Eye Color Hair Color

Place of Birth (State or Country) Social Security Number Telephone Number

Street Address or P.O. Box City State ZIP Code

Level of Service: DOJ Only

If re-submission, list original ATI number (Must provide proof of rejection):Original ATI Number

Foreign Government Embassy: (Mandatory for Foreign Adoption requests pursuant to Penal Code section 11105(c)(12))

Designee -- Do not include Employer: (Optional for individual designated by applicant to Penal Code section 11124)

Designee or Embassy Name

Street Address or P.O. Box

City State Country ZIP Code Telephone Number

Live Scan Transaction Completed By:

Name of Operator Date

Transmitting Agency LSID ATI Number Amount Collected/Billed

ORIGINAL - Live Scan Operator SECOND COPY - Applicant

Other Name Middle Initial SuffixFirst NameLast Name

Date of Birth

Last First Suffix

SexDriver's License Number

Height Weight Eye Color Hair Color

Telephone NumberSocial Security NumberPlace of Birth (State or Country)

Street Address or P.O. Box City State ZIP Code

CA0349435 ✘

DEPARTMENT OF JUSTICE

P.O. BOX 903417

SACRAMENTO CA 94203-4170

07041

RECORD REVIEW UNIT

(916) 227-3835

✘

STATE OF CALIFORNIA DEPARTMENT OF JUSTICEBCIA 8016RR (orig. 04/2001; rev. 10/2014)

REQUEST FOR LIVE SCAN SERVICE (Record Review or Foreign Adoption)

Page 2 of 2

Privacy Notice

Collection and Use of Personal Information. The Record Review Unit in the Department of Justice collects the information requested on this form as authorized by Penal Codes 11121 and 11105(C)(12). The Record Review Unit uses this information to process applications pertaining to Live Scan service for record review or foreign adoption. In addition, any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy. The Department of Justice's general privacy policy is available at: http://oag.ca.gov/privacy-policy.

Providing Personal Information. All the personal information requested in the form must be provided.

Access to Your Information. You may review the records maintained by the Record Review Unit in the Department of Justice that contain your personal information, as permitted by the Information Practices Act. See below for contact information.

Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan service for record review or foreign adoption, we may need to share the information you give us with other government agencies.

The information you provide may also be disclosed in the following circumstances:

• In response to a Public Records Act request, as allowed by the Information Practices Act;

• To another government agency as required by state or federal law;

• In response to a court or administrative order, a subpoena, or a search warrant.

Contact Information. For questions about this notice or access to your records, you may contact the Record Review Unit via telephone at (916) 227-3835 or by mail at:

Department of Justice Bureau of Criminal Information & Analysis

Record Review Unit P.O. Box 903417

Sacramento, CA 94203-4170

TO: Dental Assisting Students FROM: C. Miyasaki

Director, Dental Assisting Program RE: Fall Dental Assisting Kit

The Fall Dental Assisting Kit is approximately $500.00 (non-refundable). Do not pay for the kit now. You will be notified of when to pay for the kit.

Payment in credit card or debit card should be made by calling UCLA vendor, Wasana Ketmane, directly at 310-206-0916. If your phone call goes to voice mail, leave your name and phone number only. She’ll call you back for your credit card number. Do not leave your credit card number on her voicemail.

Payment for the student kit needs to be received by the vendor (UCLA) before the deadline given to you by the program director. If you have any questions, please email me at miyasakicara@foothill.edu or call me at 650-949-7351. Thank you.

Fall DA kit Each student will be purchasing:

• One Columbia typodont #R860 with soft gingiva• One Columbia crown prep tooth #14• One Columbia blue RDA prep tooth #3 prep tooth• Four screws for prep teeth• One pack of Googles Office Pack• 3 Tofflemire retainers .• 3 pairs of utility gloves (sizes to be determined later)• 4 cartridges of heavy Extrude PVS• 1 container of Sani-cloth disinfectant wipe• 1 box face masks• 3 boxes of non-sterile exam gloves• 1 anatomical skull project• 1 package provisional dental crowns

Foothill College Dental Assisting Uniform Policy

The uniform must be worn Monday – Friday during the months of September through June. They can be purchased locally from any uniform store or online.

You will need the following: 1. Solid colored scrubs (no prints). Black, khaki or tan.

• Pants must be straight leg (no ankle cuffs) in black, khaki or tan; and needto be hemmed so they don’t drag on the ground.

• Tops must be solid colored in black, khaki or tan.• We recommend you order several pair of tops and pants.

2. Uniform stretch scrub jacket (grey only SKU 50380) found at this URL:http://www.veterinaryapparel.com/Search/Products?searchText=fashion+stretch+jacket

3. Shoes can be tennis shoes as long as they are mostly white, all brown or all blackand remain CLEAN.

4. Surgery gown: two green cloth surgery gowns (SKU 106A0) found at this URL: http://www.professionalapparel.com/Product/505/All-Purpose-Veterinary-Surgery-Gown Gowns must be embroidered in the upper left area, see below for ordering instructions: 1. Choose Jade Green color, choose size and click Add Customization2. Click Add Text

• Line 1: Your Name• Line 2: Foothill College• Line 3: Dental Assisting• Font: choose Full Block• Thread Color: choose black

STUDENTS ARE EXPECTED TO WEAR THE UNIFORM EVERYDAY, BEGINNING WITH THE FIRST DAY OF SCHOOL IN MID-SEPTEMBER.

Taylor Swift Foothill College Dental Assisting

Foothill College Dental Assisting Sample Schedule (subject to change) Fall Quarter

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 8:00 DA 53A

8-9 DA 53A 8-9

9:00 DA 62A 9-12

DA 51A 9-12

DA 71 9-10:30

DA 51A Exams Lab testing

DA 51A Lec 9-12

10:00 DA 51A 10:30-12

11:00

12:00 LUNCH LUNCH LUNCH LUNCH

1:00 DA 51A Lec 1-2:50

UCSF Orientation DA 51A Lab 1-4

2:00 DA 51A Lab 2-5pm or

DA 51A Lab 2-5pm or

3:00 DA 53A Lab 2-5pm

DA 53A Lab 2-5pm

4:00

online class DA 50 online DA 58 online

Winter Quarter MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

8:00 DA 62B 8-10

9:00 DA 60A 9-10:50

DA 73: UCSF (1/24-3/14) 8:30-4:20

DA 73: UCSF (1/24-3/14) 8:30-4:20

DA 51B Lec 9-11:30

10:00 Model trimming 1/8, 1/10, 1/15, 1/17, 1/22

DA 56 10-10:50

Model trimming 1/8, 1/10, 1/15, 1/17, 1/22

11:00 DA 57 11-12

DA 57 11-12

Oral Hygiene with DH II Students for DA 56 1/10 – 9-11:30

LUNCH 11:30-12

12:00 LUNCH LUNCH DA 51B Lab 12-1:50

1:00 DA 100 1-2

DA 53B Lec 1-2

2:00 DA 53B Lab 2-5

DA 53B Lab 2-5

3:00

4:00

Spring Quarter MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

9:00 DA 60B 9-1

DA 74 internships 8-5

DA 62B 9-11

DA 74 internships 8-5, TBA

DA 74 9-10

10:00 DA 51C lec 10-12:30

11:00 DA 63 11-12

12:00 DA 85 lec 12-1

LUNCH 12:30-1

1:00 LUNCH LUNCH DA 51C lab 1-5

2:00 DA 53C lab 2-5

DA 53C lab 2-5

3:00 or DA 85 lab 2-5

or DA 85 lab 2-5

4:00

Please feel free to give this to anyone you think may be interested in attending the program with you.

DENTAL ASSISTING PROGRAM APPLICATION

DENTAL ASSISTING APPLICATION

Anyone is eligible to apply for the Dental Assisting Program. There are no prerequisites to apply. The only requirement for acceptance is the ability to perform the Technical Standards. If the applicant does not have a high school diploma or equivalent a short 1-2 sentence explanation is requested.

Students completing the dental assisting program will receive a Certificate of Achievement in Dental Assisting Students who have completed your college's General Education Requirements will be eligible to receive a Associate’s Degree in Dental Assisting.

NAME: Last First Middle Date of Birth

Foothill Student CWID Number (optional):

Please list any other name(s) by which you have been known: _____________________________________________

Address __________________________________________ City___________________ State_______ Zip _________

Home Phone _______________________ Cell Phone ________________________

Valid Email Address required using the following format: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Ø 1 2 3 4 5 6 7 8 9

_______________________________________________@______________________________

PRIOR EDUCATION

Do you have a high school diploma? Yes No

If yes, which high school you graduated/year? _________________________________________________________ (if you received your HS Diploma/degree outside of the United States, please indicate the City and Country where you've received it)

City _________________________________________ Country ___________________________________

If no, do you have any of the following? a. GED certificate Yes No b. Completion of college Gen. Ed. Requirements Yes No c. Secondary school diploma outside the U.S. Yes No

If you do not have a high school diploma or equivalent, please provide an explanation below: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

Please list the name, starting and ending dates, and any degrees or certificates, for all colleges, universities, technical and vocational schools attended. You must include colleges in which courses were attempted although they may not have been completed: Do not leave this area blank if you attended any post-secondary education institutions.

Name of School City and State Dates Attended Degree/s Received 1 2 3 4

TECHNICAL STANDARDS FOR THE FOOTHILL COLLEGE DENTAL ASSISTING PROGRAM

The following statements identify the technical standards needed for the dental assistant and for students enrolled in the Foothill College Dental Assisting Program. The Dental Assistant/student must possess sufficient strength, motor coordination and manual dexterity. Please answer the following questions.

Do you possess sufficient finger dexterity and eye/hand coordination to perform large and small motor coordination?

Yes No

Are you able to perform skills related to emergency procedures? Yes No Are you able to communicate both verbally and non-verbally in an effective manner to explain procedures and give instructions?

Yes No

Are you able to understand and react quickly to verbal instruction? Yes No Do you possess eyesight capable of viewing small visual images, and distinguish between black, white, and subtle shades of grey?

Yes No

If you cannot perform one or more of the technical standards identified above, you will have difficulty performing the jobs required of a dental assistant. Please explain any difficulties you might have below. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

At the end of the training program, the Dental Assistant must be able to: 1. Handle stressful situations related to technical and procedural standards of patient care situations,

thus avoiding injury to the patients. 2. Provide physical and emotional support to the patient during procedures.3. Follow directions effectively and work closely with members of the health care community.4. Perform skills related to emergency procedures required in the field

. DENTAL ASSISTING APPLICATION CHECKLIST

✓ Please make a ✓ in the available box/es to insure you have completed everything in your application. I am able to comply with the technical standards and I understand that failure to perform any of these standards may be cause for action by the program in accordance with the policies and procedures of the Dental Assisting Student Handbook, including dismissal. (Required) If accepted into this program, I will abide by all the program policies and procedures. I certify that the statements and information in this application are true and complete to the best of my knowledge. (Required) If I am accepted and enroll in the program, I understand that I need to order and send official electronic transcripts or bring official transcripts to the Dental Assisting Program Director. (Required)

Please review your application thoroughly, before signing it.

My signature verifies the accuracy of my application

Signature Printed Name Date