Please read and sign the declaration below and return the form to the HMA Office.

First Name : _______________  Last Name : _______________

I declare that I know of no claim or suit alleging negligence, error or omission against me. I am not currently the subject of a fitness to practise investigation or proceedings by a regulatory body in the UK or any other country.

I know of no complaint (or equivalent) against me, I have never been convicted of any criminal offence or been subject to any disciplinary proceedings and I know of no circumstance which could reasonably be expected to result in a complaint against me. I have never been removed from a register nor had any conditions made on my registration by a regulatory body, either in the UK or any other country.

If you are in any doubt about the facts being considered material, you should disclose them.

Disclosures Enclosed

Please tick the appropriate

Yes â–¡

No â–¡

Signed : _______________         Date: _______________