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Name of Affiliate Name of County Relationship ' <br /> or Enti Commissioner or ern Flo ee <br /> I . <br /> 3 . <br /> 4 . <br /> 5 . <br /> 6 . <br /> 7 . <br /> 8 . <br /> (si ature) <br /> 9/aa�o3 <br /> (date) <br /> STATE OF Florida <br /> COUNTY OF Escambia <br /> Personally appeared before me, the undersigned autliority, Doyle Goodman who after <br /> first being sworn by me, affixed his/be" ignature in the space provided above on this o?07 — day of <br /> September , 2003 . <br /> Notary Public , State at large <br /> My Commission Expires : <br /> 1•"Yti' "' Stephanie L Lowery <br /> :+_ XhQYCOMMISSION # [?D115484 EMUS END OF SECTION <br /> ?sluly 1, 2006 <br /> � gypp" �E BONDED TIM TROY FAIN IINSURANCE, INC <br /> 6706 -3839218/20/03 00452 -2 VRB <br />