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I, I`'� i�� C� (�'-�� .� I`� �'tLi�l'U'v ; being duly sworn, depose and confirm that the <br />preceding stat ents are true and correct, and that this statement is executed with the knowledge <br />that misrepresentation or failure to reveal information requested is sufficient cause for denial or <br />revocation of a license; that I am voluntarily submitting this application with full knowledge that <br />Minnesota law provides that any person making fa1s��lal�� guilty of perjury. <br />r � <br />Subscribed and sworn to before me this % <br />f ROBIN FRANKE <br />� � ��` e, NOTARY PUBLIC <br />���,'A ''� - MiNNESOTA <br />=1_ ,*'`� My Commissian Expires Jan. 31. 2016 <br />(Please Stamp Here) <br />Page 6 of 10 <br />hie <br />Title <br />day of �v ����{' in the year �� l� <br />, <br />/�_.��1� � �rc�.���. <br />Notaiy PuUlic <br />County of ������'� � �� <br />My Commission expires � 1��-�� ���'�C �� <br />