Ala. Admin. Code r. 445-X-1-A – Appendix

BUSINESS STATEMENT OF COMPLIANCE

I hereby certify that the following is a comprehensive listing of all individuals directly or indirectly employed by

_____________________________________________________________.
(NAME OF BUSINESS)

I certify that all employees, whether working full-time, part-time, salaried, or on commission; and who are involved in sales, fittings, and adjustments of hearing instruments or other related devices in the state of Alabama hold current Alabama dealers, dispensers, and fitters licenses and apprentice permits.

I further certify that all employees of

______________________________________________________________
(NAME OF BUSINESS)

with a permanent street address of

_____________________________________

are to the best of my knowledge in compliance with and agree to abide by all provisions of all laws, regulations, and rules of the state of Alabama governing the sale and fitting of hearing instruments therein.

_________________________________________
(NAME OF CEO)

_________________________________________
(SIGNATURE OF CEO)

_________________________________________
(DATE)

Sworn to and subscribed before me, this, the ________________ of_____________________ 19____.

_________________________________________
(NOTARY PUBLIC)

_________________________________________
SIGNATURE OF NOTARY

LIST OF EMPLOYEES

Employee's Full Name Business Address where Current
License
employee is based Number

____________________ ______________________ ___________