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i <br /> II. COMPANY DETAILS <br /> 1. NAME OF Kc�G � .TNC- <br /> MAILING ADDRESS: &JE' k <br /> CITY JLRD� COUNTY_._. --I v !) (A Q P,Li <br /> ZIP CODE: �� BUSINESS PHONE: 7/c�-,S <br /> 2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br /> etc.): <br /> 00',4W- <br /> Cj--- <br /> 0 <br /> 3. (vr^R'"^aEn-o 14AME:7 1 f -' <br /> ADDRESS: l /� \1E Ve 3�%( <br /> PHONE M 72— 5LA- Lg5q- a35 <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 /> r Of <br /> 5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br /> REFERENCES <br /> NAME ADDRESS PHONE# <br /> U:\BethOeth Casano EOCtCOPCNIRENEWAL PACKETS\COPCN Application rev.2013.doc 2 <br /> 75 <br />