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<br />CD '~ <br /> <br />Social security NUl1\ber_____ <br /> <br />-...._-""---------- <br /> <br />Oriv~r's License Number__________.__ <br /> <br />3. Full Nams <br />LAST <br /> <br />FIRST <br /> <br />FULL MIDDLE NAME <br /> <br />Date of B1rth_______ Interest.__ <br />Residence Address <br />Residence Tslephone________ <br />Social Seourity Number__.____ <br /> <br />t <br /> <br />Driver's License Number <br /> <br />4. Full MalUe <br />LAST <br /> <br />FIRST'- <br /> <br />--- <br />FULL MIDDLE NAME <br /> <br />Da~e of airth_________ <br /> <br />___ Interest <br /> <br />% <br /> <br />Residence Address___ <br /> <br />Residence Telephone <br />Social Security Number <br />Oriver's License Number <br /> <br />D_ The full name, residence address and telephone number of <br />the manager, proprietor, or other agent in charge of the <br />individual's, corporation's or association's premises to <br />be licensl'td; <br /> <br />Full Name <br /> <br />-'--. <br />FULL MIDDLE NAME <br /> <br />LAST <br /> <br />FIRST <br /> <br />Date of Birth <br /> <br />Residence Addrees <br /> <br />Residence Telephone___.__ <br /> <br />Social seourity Numb~r________ <br />Driver's Lioense Number_ <br /> <br />E. Attach a true copy of the ArtiCles of Incorporation or <br />Associ~tion Agreement. <br /> <br />5 <br /> <br />';:l,CbbQblCQ 'nil VH, <br /> <br />I-lnl-l,]wl ~'JIT1 ,(1 ;I!~ <br /> <br />o,'nl U{U.I lD_Q,_lH-Il.I <br />