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II. COMPANY DETAILS <br />1. NAME OF AGENCY: kiVe.. CcA. or -{-La ' frev_c4 uv. e. Con <br />MAILING ADDRESS: I ) I ,S W �i I f ov, z S -; <br />CITY tPo.-_-f 54-, `;,,r I e COUNTY , C U ( <br />ZIP CODE: 39 84 BUSINESS PHONE7 7.2) 29 —a' y 5- <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />MANAGER'S NAME: 4-I o { g� ��� ��� (O C <br />ADDRESS: 1g -1( S t... 17): i! —f S f . Ct Ft- 5' S <br />PHONE#: (�-i7.2) 3 -- g Lftom" <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 />tom,. C C 2 ,n ,rl_ <br />ADDRESS POSITION <br />7.20?t•,vt gt ve Y dY. <br />Pre,S (5 t1,r+e?v- <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />N e�, <br />14-L , <<, L. i c . rzELt,Iv i 60 , .713' S4 . Vero (77.2) —77 ts'-.7z,1 <br />R IAC_ ,000 ( V��.� -�S5-6 43 <br />t -i a .S ( 1 C t o F biret rt + "ZO i Ur c a r. h St l % e ►' o "7 % z) 2'1 - %' 6t7 <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />2 <br />P74 <br />