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to appear on convicted ven=ion <br /> name of the convicdreio or affiliate is <br /> T. A copy of the order of Admini§tr�f ve Hearings is a ed tis statement . <br /> ' (Draw a line through Paragraph 7 if Paragraph 6 above applies) <br /> Sworn to and subscribed before me in the state and county first mention bove on the 25th day of <br /> June , 20 03 <br /> ' J <br /> ' (affix seal) �)%�v 0 � R <br /> Notary Public <br /> 1 - 7 - 04 <br /> u� CC 897713 <br /> My commission expires OF FSO <br /> ' 044572000 <br /> 00310 (A 1 ) - 13 <br />