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Fnrm Fo. 11. � ` � -L/ �� �'.,_..1PP //on/.`'a.!.���... <br /> ` � 1 L — / 2 3 � !/i?4iIiLLG7T/ <br /> ,. �. <br /> \o.... .. ..... .....:. .............. . 5trcec. <br /> .. <br /> .. z .iL z o-- <br /> � r•e�,r�•n.................. ........................t�o% <br /> . TO TIiF. 5[iPIiRI\TI:\DI:XT OR TIIG F.\'I:RRTT \VdTP•.R CO)IP.\Nl": <br /> 1 1 lip�Jq/' nPVly for the ns�. nY��mlcr in nccordnnce �ritb lhc rules :ind n•RnlnUnns O( �Ilc I:CCPI`II. \\'i1�CP CO�11�):IIIY� illl(I reqn��et. - <br /> . L�1M1�.R,.� :!.. inch tnP br InF^rted in lhe mnin nt lLe pinrr nbocr ntnird. <br /> � Thc�Plu bnr e•ho n•111 do m>' w•ork is�.... . ,Y.•�•I.�._�..�....../....... ................................ ........� ... <br /> �...� . <br /> �!i(�l�f.t.GJ� L�G � s[� <br /> Thc a�encr ni Utc premlecv in................. ....... . ........ ................ ........ ............................ .. <br /> Thn•,�F�`nt la................._. .................. (..t�-�........._....... ... ......... ...................... <br /> ............. <br /> 7'hc h•nnnl Is..................... .................. ................................ ............ <br /> . <br /> 1 Tho �cn�rr rrnt xhnulil hc rhnrFeA lo............ 'V...................../..� ....... .i�)j.�. ...... . <br /> ' .......SIRnr•I.........�d/ /n-C�.....�.X ._,r���..�...../ <br /> � iSc� Othrr 91dr1. <br /> ... , APPlicnnt. <br /> � <br />