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WebLOC #: BLDG #: AGENCY CUSTOMER ID: REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Page 5 of 5 Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be … Webacord 130 fl (2024/07) page 3 of 3 i hereby acknowledge that i have read the above statements and personally swear that the information contained in the application is accurate. that i, as an owner / officer, am fully authorized to sign this application on behalf of the applicant and to bind the application. http://www.forms.agr.georgia.gov/GATE/images/GATEFAQs.pdf the okanagan eatery