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Town or Ci tyr; State Phone No.
Lccation of sissy
Name of busiasssl / No. Street
Squar* factaae of � . ��,1 7 Heijat cf sis.
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Maze �of Mrect.or
Addreaa
Town cr Cit7 sta:o Phane No.
Ccnaeut of Caner
The a'zove hazed �erzcn is duly aut.hcrued to Make
application on a7 beha3f. a i be ieve the atatamtent3 contailied
herein arz. true to the beat cf a7knolw e
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Application.
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PRO DS
Date 12
Reason .for rejection
132ued to t% E►� `�.
Fee ccaputa'tian C®da 01f1C:er
Date
Pee,(
VERMONT
TAEKWON-DO
ACADEMY
860-7877