BOULDER POIJCE ])EPART~JIE~TT

''--....

-------------------_.---_
.._-_.-------------------------------- ._---------_._-

[ 2!ffirm th~~t all of the infOl"mation li have girven it] ~hR~statement is ttrue and' accurate. !h2!Vti:; read
c~ch pllIge of my st~tement COIr!s~sting of i_ Wl:ge (S)l each ofwhidh bears my signatur-e.
Corrections, if any, bear nay initials.
This statement was comple~edl at:
Location

L.
--'--~~-'----

~l'!

F;vl& ~t

S-r,4PPIN

/q44

_~/7Date of Birth

1£"'/

D""~
---------

Date and

I J'o;L __

!L~
._-_/
. ceo

!fli{
llX iifle
'(-1.

.c .. _.

I ';)

._-------

01

_

Sign up to vote on this title
UsefulNot useful