Laserfiche WebLink
II. COMPANY DETAILS /� <br />1. NAME OF AGENCY: 17\-- /4(C- Of /flfaki kivcr COUY1 / 1C� <br />MAILING ADDRESS: 13(5 ) <br />CITY VQXO Beaus COUNTY I lCile• iU <br />ZIP CODE: 3299 (co BUSINESS PHONE: 272. -56z- <br />2. <br />72 -S- <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />/lore - Pg_oFi , Coze Tt on) <br />3. MANAGER'S NAME: Ch1e.s A. eat <br />ADDRESS: Ito ni Ave-- 004c3 jr,Q.Ck 32qhb <br />PHONE#: *-1-72-76b-(e2iQ) <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 />ADDRESS POSITION <br />0 Eg A ISeAkel 6 Jo Ave- sTi (- L 321V E)(E Et oL _ <br />Nz D'-tfr_ cNt /.\, aIL Ass . pleas <br />`l U E ai-A L E -S 5Xo yON.o 1)e at -AA J21%y <br />AmitcHa9 Die -Eau -5 L►S-T"I i(, <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />ac, AO i -fie - /93 ( Coir iliacE Ne 32c E,c, -272-37,2 -2./t, 3 <br />'T1 a F VSo Ld ► Cr7) a i7E s Po L oX 11Zn , 2, 2961 779 --S 100 <br />/Abo,3 R' J O/ 1 OLJI C, t / 7 okattkkt � tA) P6 772 - 2q1 - /v 92_ <br />a.3Y 17 <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />2 <br />P62 <br />