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II. COMPANY DETAILS <br />1. NAME OF AGENCY: 77 -le AKC OF /NDiitJ / /E) Coc1Nw/ lt& (ritw'z.y <br />sumo P A iec <br />MAILING ADDRESS: /37S- <br />/6 q- <br />'JE <br />CITY Veto £SCE-( COUNTY INO(AA kl✓C�2 <br />ZIP CODE: 31%D BUSINESS PHONE: 772 - S(oZ - loyS y <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />/tom - P2or Ca,epo2� �1 o,3 <br />3. MANAGER'S NAME: CN -AQ -u ---S / . 6k/1- DLO, &)(E _ 'b 1 e . <br />ADDRESS: I37 / ANE V azo B940-1 32966 <br />PHONE #: Q 772. - 766 /`f3 g <br />4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS, <br />DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (attach a <br />separate sheet if necessary): <br />NAME <br />CI -Mate -5 q-, 824-oL.E1 <br />1 -k's - n -t -C-42 Dc -L S <br />j uc0 IT34 L (C-Lv IL SS'D y 2r z. c VEY20 32-968 <br />SEE• A TM -c -1 -len 1 2-EZias Cts i <br />ADDRESS POSITION <br />6s9 ,102.oA-•J q-Ve, SEeA-sT7A,) i 3Z6‘3 bf P • <br />Ig q'te -7-41-Sw v2 ,6e)-104 Ass -r. e(ec. 11121 <br />0614 P712.o LLE <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />evi-a-ILe2, e- e--, ,4Jc±'k <br />CE 81-cc.e ARei-,r INc- <br />vaA3 Boa 3-2)1(6 N E9ia mc. <br />1°136CoMMt CA1C-3Zyoo <br />Pb 8ox I/ob, 73( I <br />Po fox i3gi, 3461 <br />U.\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />774 -36Z-2Io3 <br />-772_ -Seq- 99 <br />772 -22 -7q2 <br />2 <br />138 <br />