Part G: Treating Professional’s Signature and Declaration

You must complete Part G. Section 2 cannot be processed without the Treating Professional’s endorsement (i.e. signature and date) below.

By signing this document:
– I certify that the information I have provided is true and correct, and that I have supplied all of the available information and documents needed for the applicant’s application.
– I understand that giving false or misleading information is a serious offence.
– I consent to being contacted at a later date by an NDIA representative if required.

1. Treating Professional’s signature:
2. Treating Professional’s full name:
3. Date: (DD/MM/YYYY)