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Page 3 <br />Date Of B�rtih Tnterest � <br />Residence Address <br />Residence TeZephone <br />Business Address � <br />Business Telephone <br />B. The managing partner will be <br />7� A, If the applicant is a corporation or association, give the <br />name of corporation or association, branch address and <br />telephone number, and home office address and telephone <br />number: <br />Name <br />State of Incorporation or Association lv1�r}h� ��� <br />Branch Address <br />Branch Telephon� Number {Q5� • 4-�� '[ 5�S <br />Home Office <br />P� ur fnsv�`1 <br />Home 0 fice <br />B. The full names, residence address, and telephone numbers a� <br />al1 officers of said corporation or association: <br />p=aS 3d�t ��e Q+�a ch � <br />LAST FIRST FOLL ffiIDDLE NA� <br />Residence Address <br />Residence Telephone Number <br />DaCe Of Birth <br />Vice Preaideat <br />LAST FIRST FULL �IDDLS NA� <br />Residence Address <br />Residence Telephone Number <br />D�te of Birth <br />l3 <br />