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II. COMPANY DETAILS <br /> 1. NAME OF AGENCY: <br /> MAILING ADDRESS: ` l466 <br /> CITY COUNTY 1�e,j.,j <br /> ZIP CODE: BUSINESS PHONE: <br /> 2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br /> etc.): <br /> 3. MANAGER'S NAME: <br /> ADDRESS: <br /> PHONE #: <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 ADDRESS POSITION <br /> mgrs\Ca6--cp <br /> 5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br /> REFERENCES <br /> NAME ADDRESS PHONE# <br /> 3a\) <br /> -2,c-\ , Q-4- e—' <br /> U-\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc 2 40 <br />