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(11) Any further information which the state may require, or any further <br />information which the collector may deem necessary to properly identify <br />the applicant. <br />(12) A signed statement made under penalty of perjury that the statements <br />therein are true and correct, which statement shall be required to be filed <br />with the collector upon submission of any original license application, <br />annual renewal statement, miscellaneous supplementary statement, or <br />other return or filing. Each such declaration of truth of application or <br />statement shall have included therein, or attached thereto, a certification <br />or declaration, which shall be substantially in the following form: <br />I declare, under penalty of perjury, that this application, return or <br />statement (including any accompanying schedules, statements, and <br />supporting data) has been examined by me, and, to the best of my <br />knowledge, information, and belief, is a full true and correct application, <br />return, or statement and I accordingly so represent. <br />(Signature of Owner, or Partner, or (Date) <br />Officer of Corporation, or Other <br />Authorized Agent or Representative of <br />an of the above said same) <br />(13) In the case of applications submitted via email, the collector in his or her <br />discretion may accept a facsimile copy of the applicant's signature; <br />(14) In the case of applications submitted via other electronic means, the collector <br />in his or her discretion may accept a digital signature or other unique personal <br />identification number (PIN) verification. <br />All information specified to be set forth on any application form prescribed by the <br />collector shall be submitted completely and accurately and the license shall be deemed <br />based upon the information submitted and represented. The collector shall not be <br />required to receive or consider, any application, return or statement unless the above <br />quoted declaration, in substantially the form hereinabove set forth, is contained therein <br />or attached thereto and properly executed by the applicant or the authorized agent or <br />representative of the applicant, and it is unlawful and shall be deemed a misdemeanor <br />in any such application, return or statement for such applicant or authorized agent or <br />representative of the applicant to make any statement which is false or which is contrary <br />to the declaration or representation made in the above quoted form. <br />Any license shall be deemed based upon the application on file, and if the <br />information is incomplete or inaccurate, the license shall be deemed invalid. If <br />information submitted in an application subsequently becomes incomplete or inaccurate <br />by reason of a change in circumstances, the license shall thereafter be deemed invalid. <br />Page 20 <br />11 A-22