05 - LD Talk Client Confirmation — Bethel Community Services, Inc

Bethel Community Services, Inc

Legal Talk Confirmation

Please complete for
each person
requesting documents

Full LEGAL Name

Please provide your full legal name and not your nickname or common name. (i.e Please use Joseph and not Joe or Joey)

Have you completed "The Talk" video?

Yes

No

Certification Statement

I certify the information submitted in this form is true and correct to the best of my knowledge. I further understand that any false statements may result in denial of program participation.

Full LEGAL Name

Have you completed "The Talk" video?

Yes

No

Certification Statement

I certify the information submitted in this form is true and correct to the best of my knowledge. I further understand that any false statements may result in denial of program participation.

Full LEGAL Name

Have you completed "The Talk" video?

Yes

No

Certification Statement

I certify the information submitted in this form is true and correct to the best of my knowledge. I further understand that any false statements may result in denial of program participation.