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