Enclosure (5) to COMDTINST 6010.2B
Attestation
NAME: _____________________________________________________________
(Last, First, MI printed)
SSN: _________________________________
DOB________________________
I affirm and attest that all information submitted by me in this application is correct and complete to the
best of my knowledge and belief. I acknowledge that any material misstatements in or omissions from
this application may constitute cause for denial of my application for staff membership or participation.
I have the responsibility to comply with USCG policies and procedures for Medical and Dental Staff,
and to abide by USCG Standards of Conduct. I will keep my file current by informing COMDT (CG-
1122), of any changes, including but not limited to: my demographic information, my state license(s),
certification(s), any change in my medical staff/employment status at any facility, any change in my
professional liability insurance coverage, or the filing of a lawsuit against me.
Signature: _________________________________________
Date: _____________________
Witness: __________________________________________
Date: _____________________
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