Signature
For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name, title and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form subjects the signatory to the same responsibilities as a hand-signed form. Per Section 18-8-306, C.R.S., it is a felony to submit false information to a state official.
I certify that all statements made in this application are correct and complete. (Note: Providing false statements in this appication or providing fraudulent identification constitutes second degree perjury as defined by 18-8-503, CRS.)