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16. If no witness is otherwise available, the Government Officer receiving this application in person shall serve as such witness upon request. Mailed applications MUST be signed by a witness as well as by the applicant. Signature Witnessed By: Signature of Witness Typed or Printed Name of Witness Address of Witness Day Evening Telephone Numbers of Witness Typed or Printed Name of Such Person eee Dernonst Rox an, Gs ama ‘ neato tw Position or Responsibility of Such Person Relative to Proposed Demonstration vol foventng Sane Telephone Numbers of Person Filing NOTE: Under 18 U.S.C. 1001, any person who knowingly and willfully faisifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false statements or representations, in respect of any matter within the jurisdiction of any department or agency of the United States, is liable to a fine in an amount up to $10,006, and imprisonment for not more than five years, or both. SUAUIS utd TRO! SENGAS Ss fs. GL Hd 60 7 y uy, GSAIs93y CO910 b6 67C b6 b7C b6 b7C