SAMPLE
Independent Witness Statement
I hereby state that I was a witness at the "Break a World Reading Record with Charlotte's Web" Event on December 13, 2006 at: (List the name and address of the participating school or site)
 
 
 
I have abided by the guidelines presented to me and was "on duty" at

_____________________________________________________ on 12/13/06.
(list the start time and time zone)




Name (please print):  
Signature:  
Organization:  
Title:  
Street Address:  
City:  
State:  
Zip:  
Telephone Number:  
Email Address: