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II. COMPANY DETAILS <br />1. NAME OF AGENCY: LJ EAR of 1-7/6 <br />MAILING ADDRESS: m7/ 314 ')z.rrr- �i • <br />CITY (P,,RTS V , Luc( - <br />COUNTY ,S,', Luc <br />ZIP CODE: ,)1/18L-/ BUSINESS PHONE: 77) - 39 -UFyS <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />rt VATE' <br />3. MANAGER'S NAME: NICoL&, I(,00k1Az,.3' <br />ADDRESS: )ci11 Svi 33)crre (k 51Th ` avv 3yggy <br />PHONE #: 71a- 348-a8ys <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 />{ANA AL.An, S (V\ Kt's" <br />ADDRESS POSITION <br />J11...rnY)irtI ST' <br />0'.T �� . �-• c,e rL 3imv <br />P&: St aLrM/ <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />tALTHcSoc/ 11 ►(VinuAi L /t v 3-r - cko c\ 1 JR_ - )10,5 <br />-oil,' i -n,' AstiAt Gone ' 51)b) bunt J af). 1/63-F>'9tu <br />li A G S:.d CA- S► , LuqC )75 4ci- Pc S;: La -1, FL — - 335--nyy <br />UY\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />2 <br />150 <br />