Return to List of Exhibits and Figures
I, [name of individual], do solemnly [swear or affirm] that when given access to the [title of data to be provided] provided by [name of the agency or school], I shall not:
Signature: ______________________________________
Name: ______________________________________
Title: ______________________________________
Organization: ______________________________________
Date: ______________________________________
The penalty for unlawful release is [maximum penalties as specified by the applicable laws and provide citations].
Notary Public and Seal: ______________________________________