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H. COMPANY DETAILS <br /> 1. NAME OF SERVICE: jxc'c I (UrC(Cc71 UYl <br /> MAILINGADDRESS: _ (Qty ( t( S'("• <br /> CITY V= &aCj, R-70 <br /> UNTY � <br /> ZIP CODE:34(00 BUSINESS PHONE; <br /> I <br /> 2 TYPE OF OWNERSHIP(I a Private; Government, Volunteer, P rtnership, <br /> etc- i <br /> --fir rD �- <br /> 3. MAN AG€ID'S'NAME fur! <br /> ADDRESS: L(3 5 Ll"�reA AU—L . Ul'D6,m� -�2-9eo7 <br /> PHONE #: — � )J <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 /> 5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br /> REFERENCES <br /> NAME ADDRESS PHONE# <br /> i (Td t Jaj-1 kff�v�� f t�' Are V/ -:ti ocyh Fc 3�2 �a 7 -�qQa <br /> CG ty) PC 18� a,7 -H-? O' rf L4, Ycl-z) -eio 7,9 <br /> U:OethWeth Casano EOCICOPCMRENEWA!_PACKETSWKN Application rev.2013.doc 2 <br /> 55 <br />