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c. the applicant represents and warrants that no party other than those mentioned in item B above has any interest, direct or indirect, in the transaction or transactions for which a license is applied for herein. If there are any exceptions, note them below.

D. The applicant represents and warrants that, except as specifically stated, he has personal knowledge of all the facts herein stated; that the same are correct and true: and that he does not have knowledge of any material facts in connection with such application which are not fully and accurately set forth herein.

E. The applicant represents and warrants that he has complied, and agrees that he will comply, in all respects, with all provisions of Section 3(a) of the Trading with the enemy Act, as amended, Executive Order No. 8389 of April 10, 1940, as amended, and all regulations, rulings, orders and instructions issued by the Secretary of the Treasury thereunder or under the authority of section 5(b) of the Trading with the enemy Act, as amended, and with any and all licenses issued to the applicant pursuant thereto.

F. The applicant represents and warrants that no other application for a license authorizing the transaction here involved has been filed or is pending, except as follows:
________________________
(signature of applicant)

If this application is filed by an agent, attorney, or other person, for or on behalf of the applicant, the following statement should be executed.) 
I,______________, certify that I am the ________________________________
(State relationship to applicant)
of _________________(name of applicant)_____ who is the applicant in the above application for a license; that I am duly authorized to make the foregoing application on behalf of the applicant; that, except as otherwise specifically stated, I have personal knowledge of all the facts herein stated; that the same are true and true and correct; and that I do not have knowledge of any material facts in connections with said application which are not fully and accurately set forth herein.


___________________
(Signature of Agent)

___________________
(address)

RECOMMENDATION OF FEDERAL RESERVE BANK

The above application is forwarded to the Secretary of the Treasury with the recommendation that a license should be (granted).
(denied).

Remarks:____

Note: If this application is executed outside of the United States, it must be executed under oath before a diplomatic or consular officer of the United States.

If this application covers gold in any form the provisions of the Provisional Regulations issued under the Gold Reserve Act of 1934 must also be complied with.

Attention is directed to Section 35(A) of the United States Criminal Code, which provides, in part:

***whoever shall knowingly and willfully falsify or conceal or cover up by any trick, scheme, or device a material fact, or make or cause to be made any false or fraudulent statements or representations, or make or use or cause to be made or used any false bill, receipt, voucher, roll, account, claim, certificate, affidavit, or deposition, knowing the same to contain any fraudulent or fictitious statement or entry in any matter within the jurisdiction of any department or agency of the United States ***, shall be fined not more than $10,000 or imprisoned not more than ten years, or both.* Act of April 4, 1938, ch. 69, 52 Stat. 197 (U.S.C. tit. 18, sec. 80)

Copies of this form may be obtained on request, at any Federal Reserve Bank, mint or assay office, or the Treasury Department, Washington, D. C.