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2003 FOR PROFIT ' ""' ORPOR TION <br /> UNIFORM BUSINESS AE10ORT ( UBR ) <br /> DOCUMENT # F72845 E , <br /> 1 . Entity Name of <br /> DICKERSON FLORIDA, INC. <br /> Principal Place of Business Mailing Address <br /> 3340 S.E. DWE HGHWAY P.O. DRAWER 719 <br /> P.O. DRAWER 719 MAU R 34995 <br /> MAU FL 34995 US <br /> 2. Principal Place of Business 3, Mailing Address ��I���1 III! �II�� IIID fUII ��I�� IIII I�III rll��l ILII IIIA �t��I II��I <br />I1 , <br /> Suite, Apt. #, etc. -Suite, Apt. #, etc. <br /> ❑ CHECK HERE IF MAKING CHANGES <br /> City & State City & State 4. FEi NumberApplied For <br /> 56-1327509 tl <br /> Not Applica. <br /> � Country P Coun . Zip Country $8 .75 Additional <br /> 5. Certificate of Status Desired L� <br /> Fee Required <br /> 6. Name and Address of Current Registered Agent 7. Name and Address of New Registered Agent <br /> Name <br /> DALE, LARRY T <br /> 3340 S.E. DWE HIGHWAY Street Address (P. O. Box Number is Not Acceptable) <br /> STUART FL 33494 <br /> city FL Zip Code <br /> 8. The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both , in the State <br /> of Florida. t am familiar with, and acce <br /> the obligations of registered agent. <br /> SIGNATURE <br /> sgnWYe, Wed or vied name of registered agent and tine a applicable. (NOTE Regmtemd Agent elgnmwe rocii when reinstating) ogre <br /> � . <br /> 9. Electi Financing <br /> on Campaign $5,,00 May Be <br /> " - - Trust Fund Contribution. ❑ Added to Fees <br /> 10' OFFICERS AND DIRECTORS 11 . <br /> ADDITIONS/CHANGES TO OFFICERS AND DIRECTORS IN 11 <br /> TITLE P ❑ Delete TITLE <br /> NAME DALE; LARRY T. NAME <br /> ❑ Change [3addition <br /> STREET ADDRESS 798 POLYNESIAN AVE: NAMSTREE <br /> TADDREss <br /> CITY-ST-ZIP PT. ST. LUCIE FL CITY- Sr-ZIP <br /> TITLE V ❑ Change ❑ Addition <br /> C3 Delete TITLE <br /> NAME PALLAS, CHARLES W. NAME <br /> STREET ADDRESS 2790p COOLIDGE ROAD STREET aDDREss <br /> CITY- ST-ZIP Fr. PIERCE FL CRY-Sr- i7P <br /> TM.E ❑ Delete NME ❑ Change Additi� <br /> D ❑ <br /> NAME JOYNER, JOHN Foot <br /> STREET ADDRESS 1501 OLD CHARLOTTE HWY STREET ADDRESS <br /> CITY-Sr- nP MONROE NO CITY- ST- zIP <br /> NAI VP ❑ Change ❑ Additit. <br /> NAME MEADE-$RANN, WENDY ❑ Delete � <br /> STRREETADDRESS 4101 LOOKOUT COURT STREET ADDRESS <br /> CITY-ST- ZIP FORT PIERCE FL 34951 CITY- ST- ZIP <br /> TITLE VPTITLE <br /> ❑ Change Additir <br /> NAME BARRILE, BERNARD ❑ <br /> Delete NAME <br /> C3 <br /> STREETADDRESS 421 DEWBERRY TERRACE STREET ADDRESS <br /> QTY- ST-aP JENSEN BEACH FL 34957 cm=Sr-nP <br /> ITrLE VP . <br /> ❑ Delete TRLE ❑ Change ❑ .AdditiL <br /> 0-ME HEIIIAR LARRY D JR IM <br /> STREET ADDRESS 1082 SW LONGFELLOW ROAD STREET ADDRESS <br /> -� - ST-ZIP PORT SAINT LUCIE FL 34953 crnr- sr. zlP <br /> 12. I hereby certify that the information supplied with this filing does not qualify for the exemption stated in Section 119.07(3)(1), Florida <br />Statutes. I further certify that the information <br /> indicated on this report or supplemental report is true and accurate and that my signature shall have the same legal effect as if made under oath; <br />that I am an officer or director <br /> of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 607, Florida Statutes; and that my name appears <br /> in Block 10 or Block 11 V <br /> changed , or on an attachment with n address• with al other like empowered. <br /> SdCaNATJRE :4 `AWRY T Lw �6 f+ GL3 77a d � - A <br />