Signature of AppointeeMiddle InitialFirst NameLast Nameaccording to the best of my ability Xday ss TYPE ALL INFORMATION SIGN IN BLACK INK Go to wwwdosnygov for filing instructions ID: 387177
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DOS-1692-f-l (Rev. 09/14)SENATE or ASSEMBLY MEMBER, OFFICER or EMPLOYEE OATH/AFFIRMATIONName of Appointee: STATE OF NEW YORK))COUNTY OF )I do solemnly swear (or affirm) that I will support the constitution of the United States, and the constitution of the State of New York, and that I will faithfully discharge the duties of the office ofTitle of Position:House of the Legislature:Sworn (or affirmed) before me this of , in the year, 20.Notary Public (Signature of Appointee)(Middle Initial)(First Name)(Last Name)according to the best of my ability. Xday ss.:( TYPE ALL INFORMATION -- SIGN IN BLACK INK )Go to www.dos.ny.gov for filing instructions.