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The licensee is a Equal opportunity employer Minority or women business enterprise Small business Disadvantaged business enterprise INELIGIBILITY FOR PUBLIC WORKS Has the licensee ever been listed by the Commissioner of the Bureau of Labor and Industries BOLI as ineligible under NO YES ORS 279C. Oregon.gov/ccb Eff. date Do not write in this box. Full Legal Name of Sole Proprietor Partnership Corporation or LLC CCB License No. Business Mailing Address Telephone Number City State Cell Phone...

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