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SUBSCRIBED SWORN TO before me this day of 20 Date Stamp LIC. No. Type Expires on APPLICANT NAME D/B/A PROPOSED LOCATION MAILING ADDRESS Contact Person/Agent Ph Email LICENSEE INFO TAX HOLD OUTSTANDING CITATIONS Application Fee of 200 Y N Appointment of Personal Representative submitted Y N Comment Attached if applicable Last Will Testament if available Y N Comment Letters of Testamentary Y N Comment Comment Title / Name FPs submitted on / Date Cleared Server Revised 1/26/2017. The licensee...
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