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II. COMPANY DETAILS <br />1 NAME OF AGENCY <br />MAILING ADDRESS. <br />CITY C COUNTY <br />ZIP CODE: BUSINESS PHONE: <br />2. TYPE OF OWNERSHIP(i.e Private, Government, Volunteer, Partnership, <br />etc.), <br />3. MANAGER'S NAME: LO t (1, 1 e -S <br />CCL <br />ADDRESS.- �1 <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 />A/ <br />C C <br />CL <br />5 <br />NAME <br />PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />ADDRESS <br />PHONE# <br />U \Beth\Beth Casano E0C\C0PCN\RENEWAL PACKETS\COPCN Application doc <br />4 <br />