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The undersigned, a duly authorized representative of the Applicant, hereby <br />certifies that the foregoing information is true, correct, and complete as of the <br />date hereof and agrees that the Applicant shall be bound by the terms and <br />provisions herein. <br />APPLICANT' S NAME <br />DATE <br />SUBMITTED BY <br />TITLE <br />EMAIL ADDRESS <br />TELEPHONE NUMBER <br />CITY ACCEPTANCE OF APPLICATION <br />DATE <br />FEE AMOUNT REMITTED <br />DATE <br />m <br />