Statement of Mr. John Doe

I, John Doe, of 17 Grisham Court, 104 Brians Park Road, New Southgate, London, Nil 7EZ, UK do confirm as follows:

I am currently employed on a full time and permanent basis as a Surgeon.

My employer is King’s Clinic, The Grange, 104 High Street, Southgate, London N14 6PW

My employers contact number is 020 777777777

My father’s name is Abraham Doe and his address is 81 Marylyn Road, Mitcham, Surrey, CR4 1JY. My father is retired.

My mother’s name is Abby Doe and her address is 81 Marylyn Road, Mitcham, Surrey, CR4 1JY. My mother is retired.

I confirm the above to be true and correct.

Signed:

Dated: