TABLE III |
I, (panel member), hereby affirm that, as a member of a prelitigation panel, I will discharge my responsibilities without bias towards any party. I also affirm that, to the best of my knowledge, no conflict of interest exists as to any matter which will be entrusted to my consideration as a panel member. |
Dated this (day) day of (month), (year). |
(Signature) |
Utah Admin. Code R156-78B-8