Oregon State Landscape Architect Board by m4N9Vg

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									              AFFIDAVIT OF RESPONSIBILITY


Oregon State Landscape Architect Board
1193 Royvonne St SE #19
Salem OR 97302


Members of the Board:


I, ___________________________, will be serving as the “in responsible charge”
Landscape Architect for the following Oregon Landscape Architect Business. My
registration number with the Oregon State Landscape Architect Board is:
__________________.

Business Name: ___________________________________

Business Address: _________________________________

                  _________________________________

Phone: __________________________________________

Fax: ____________________________________________

Email: __________________________________________

By my signature, I confirm that I am serving as the LA in responsible charge of all
landscape architect work at the above stated business.

_________________________________
Signature

_________________________________
Date

______________________________________________________________________________
My work address location if different from business address above

								
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