Examination Custodian Declaration

DECLARATION  OF CUSTODIAN FOR EXAMINEE

 
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)
 
____________________________________
                          (Signature)