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K" <br />(Corporation Page 2) <br />hlr)l name <br />Home Address: <br />Phone Number <br />Interest <br />Date of Birth <br />hull name <br />Home Address: <br />Phone Number xo�ne <br />Interest <br />Date of Buth <br />Middle last <br />Manager, proprietor or other agent in charge of the corporation or association to be licensed <br />Fullnaan.e Pu)tGUY LEON <br />Morrie Adch ess; <br />Phone Number xomc wort <br />Date of Birth <br />