Form Chr-1 - Registration Statement Of Charitable Organization Page 4
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CERTIFICATION
We the undersigned, being duly authorized to act on behalf of the applicant, do hereby certify
that the information furnished in this registration is true and correct to the best of our knowl-
edge, information and belief.
Authorized Officer:
Date
Signature
Title
Type or Print Name of Applicant:
State of
, County of
Subscribed and sworn before me this
day of
,
Notary Public
My commission expires
Chief Fiscal Officer:
Date
Signature
Title
Type or Print Name of Applicant:
State of
, County of
Subscribed and sworn before me this
day of
,
Notary Public
My commission expires
Revised 1/08
Issued by the Secretary of State, State Capitol, Charleston, WV 25305
FORM CHR-1
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