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� <br /> ��� ! - -- _ . ._- - --- - � - �� 1 <br /> ya � �-c,� <br /> ' Data / d -JU ' �J' �._- Fee $�- G�, (l V _ <br /> ((C�VERAL� APPLI TION FORM) <br /> �PIFASE PRINt <br /> Name of Business )��f'/y/q�j/r+5 ////F/�' ��/�F �.IJ.0 _ Business Phone 3 rj S Q S,SS � <br /> Busi�ss Address � O 9 /.��n.,�T /rc,� �j���lT / L�Ij.Sl�� 9{� `��!�y <br /> (No. &��) (City); (State) iZip) <br /> lype of Business On7anization: Sole Proprietorship Partnership _ Corporation y� <br /> If business organization is a corporation, di=.regard the remainder of this appli.cation and <br /> attach a list of ccrporate of£icers including hane address, telephone ntmiber and birthdate of <br /> each per.son. If bL.ainess organization is a partnership, each partner must fill out an appli- <br /> cation. If busines:; organization is a p�tnership or a sole proprietorship, continue on with <br /> this application. <br /> N� girtixiyte Ha�e Phone <br /> Ass�un�.d Names or Aliases <br /> � <br /> i Hcme Acldress <br /> (No. & Street Name) (City) (State) (Zip) <br /> Previous address for two years past: <br /> Driver's <br /> ��, �, ' Vehicle Make Vehicle Model <br /> Vehicle Year Vehicle Color Lic. P1ate Number <br /> References--Name and address of four persons who have known you for a period of t�,o years (no <br /> relatives) : ' <br /> N� Address <br /> i <br /> I �— <br /> I� ,�; <br /> � % � <br /> /� � , )' <br /> �l: � /� .'L'n�N „�L�/°---- , <br /> ,� Signat fe ot' Applicant Bond <br /> � <br /> Insurance <br /> Ap�roved Nejected Treas. Rec. # �,-�U r/�- <br /> License # <br /> ✓Pp lice Dept. Date Issued <br /> �✓F' re Dept. gY <br /> dg. Dept. <br /> � <br /> J <br /> L <br />