BEFORE ME, _______________________, Notary Public in and for ______________(name of the state/country)___________, duly commissioned and qualified, personally appeared _______________________, who being duly sworn, declares and says:

1. that his signature appearing hereon above his name is his true signature;
   
   
2. that his present residential address is _______________________;
   
   
3. that his date of birth is _______________________; and
   
   
4. that his nationality is _______________________.
   
   
   
   Date: _______________________
   
   
   

_____________(name)__________, Notary