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Has been verified

iviae
cenifi*i
f"l Gi"ui,"E
- **
Shallbe oblained from rhe applicaD(sJ withiD thrEe moaths
lvide
certificate (a) (i)
and
(iv)
abovl
Date I
(Sigoature
ofthe Authofted Ofnciat)
Nme. . . . . . . . . . - . . _______,
Desi 9na1i on. . . . , . . , . . . . . . . . . . . . .
N&n and address of
theAurhorised
Dealer....... ... .
*Strike
out item no1 applicable,

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