I, First Name* Last Name* of Street Address* Address Line 2* City* State* Zip* occupation * I do solemnly and sincerely declare that: 1. As a facilitator or business owner under the banner of Rod Catterall & Associates, I agree to be bound by their `National Code of Practice' , Confidentiality Agreement, Licensing Agreement and Sub Contractors Agreement. 2. I understand, acknowledge, accept and agree that should I breach the above mentioned agreements in point 1, then my trainer certification and all such privileges will be revoked and all such privileges would cease immediately.3. I understand, acknowledge, accept and agree that should my first aid or insurances lapse or I obtain a conviction against my name, my terms and conditions of being certified and insured under Rod Catterall & Associates will be revoked and all such privileges in conducting business and providing services under the RCA would cease immediately. I acknowledge that this declaration is true and correct, and I make it with the understanding and belief that a person who makes a false declaration is liable to the penalties of perjury. Declared at Street Address* Address Line 2* City* State* Zip* in the state of Victoria, on Date* by First Name* Last Name* Signature* Signature of person making this declaration. (to be signed in front of an authorized witness) Before me Signature* First Name* Last Name* Street Address* Address Line 2* City* State* Zip* Title* Signature of authorized witnessThe authorised witness must print or stamp his or her name, address, and title under section 107A of the Evidence Act 1958 (Vic). (Eg Justice of the Peace, Pharmacist, Police Officer, Court Registrar, Bank Manager, Medical Practitioner, Dentist. some public servants)
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