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Emeritus Status Request

Personal Information

Work Information

Home Address

Emeritus Status

Applicant's Certification and Attestation

I have read the above Emeritus Status Application, and understand it. I hereby certify and attest that all of the information on this form provided by me is true and complete. I am aware that submitting false information is, in and of itself, a sufficient ground for a revocation of any designation governed by the National Association of Health Underwriters.