Regulatory Standing Form

Is this Applicant currently Registered/Licenced/Certified?
Has the Applicant's Registration/Licensure/Certification been denied, revoked, restricted, suspended or under review at any time?

I hereby certify that:

• The Applicant has authorized and directed me to provide this form directly to COPR;

• I am the Registrar responsible for regulatory oversight of the Applicant;

• The information I have provided is, to the best of my knowledge, true, accurate and complete.

Sign above