J.12 Key Individual Certs for Narcotics and Drug Trafficking.pdf

Mandatory Reference: 206 Supplementary Reference: N/A File Name: ads15/20657m1

KEY INDIVIDUAL CERTIFICATION

NARCOTICS OFFENSES AND DRUG TRAFFICKING

I hereby certify that within the last ten years:

1. I have not been convicted of a violation of, or a conspiracy to violate, any law or regulation of the United States or any other country concerning narcotic or psychotropic drugs or other controlled substances.

2. I am not and have not been an illicit trafficker in any such drug or controlled substance.

3. I am not and have not been a knowing assistor, abettor, conspirator, or colluder with others in the illicit trafficking in any such drug or substance.

Signature: ________________________ Date:

Name: ___________________________

Title/Position: ____________________________

Organization: _____________________________

Address: ________________________________

Date of Birth: ______________________________

NOTICE:

1. You are required to sign this Certification under the provisions of 22 CFR Part 140, Prohibition on Assistance to Drug Traffickers. These regulations were issued by the Department of State and require that certain key individuals of organizations must sign this Certification.

2. If you make a false Certification you are subject to U.S. criminal prosecution under 18 U.S.C. 1001.