Examination Custodian Declaration
I, __________________________________, of
___________________________________________, hereby declare that
_________________________________ has been in my presence and
custody from the time of ____________ to _____________ on
During that time said examinee did not have contact with anyone
involved in the _________________________ examination and did not
communicate with any other person about the contents of the examination.
I have read the foregoing and hereby declare under penalty of perjury,
that the foregoing is true and correct.
Executed on _____________, at _______________________, __:__
(Date) (Location) (Time)