On this ______day of ______, in the year 20______, personally appeared before me date month year. Learn what an acknowledgement receipt is and how to create one for your business (with a template and two examples).On this ______day of ______, in the year 20____, before me,. A form for the employee to sign acknowledging receipt of the policies. Following are samples of these provisions. Here are three examples of effective acknowledgement statements. On this _____ day of ______, in the year 20__, before me,. , personally appeared. All you have to do is fill out our easy-to-understand questionnaire. Here are three examples of effective acknowledgement statements.