DEBRA A. VALENTINE
General CounselCONNIE WAGNER
SARAH L. KNAPP
JAMES A. PRUNTY
Â鶹´«Ã½ 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 Â鶹´«Ã½ 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 Â鶹´«Ã½ 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 Â鶹´«Ã½ 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 Â鶹´«Ã½, Â鶹´«Ã½ 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 Â鶹´«Ã½ 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 Â鶹´«Ã½ 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
Â鶹´«Ã½ 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 |