AGREEMENT AND RELEASE (Please read the following statement carefully).
This certifies that my qualification form was completed by me and all
entries on it are true and complete to the best of my knowledge. I also
agree that falsified information and significant omissions may result
in my disqualification now or at any time.I understandthat an
electronic signature will be binding upon me, I authorize any and all
persons and/or institutions to provide any relevant information,
including but not limited to my accident history, that may be required
to complete my qualification and I agree to release them from any
and all liability for supplying said information.