AFFIDAVIT OF COMPLIANCE
STATE OF _______________________________ )
COUNTY OF ______________________________ )
I, ____________________________, being first duly sworn, depose and say:
I am the person named who has signed this application for approval of continuing education credit by the Idaho Mediation Association (IMA). By signing this application, I attest that I have fulfilled the requirements set out in the application form upon which I have submitted my name, and agree to continue to abide by Idaho Mediation Association Ethics and Standards of Practice and Grievance Procedure.
I understand that the determination as to whether I continue to be certified as a Professional Mediator depends on the truth, falsity, or completeness of my answers set forth in this application and the statement attached.
To my knowledge, the answers and information which I have supplied in connection with this application are true and complete.
Applicant's Signature: ________________________________________
Subscribed and sworn to before me this ______ day of ____________ , ______
_____________________________ NOTARY PUBLIC SIGNITURE
_____________________________ RESIDING AT
_____________________________ MY COMMISSION EXPIRES