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Get Lic200a 2008-2024

ONLY DISTRICT: COUNTY: FACILITY NUMBER: DATE: ACTION TYPE: REVIEWED BY: FACILITY TYPE: 1. 3. APPLICANT(S) NAME(S) 2. REQUESTED ACTION (CHECK ONE): â–  â–  â–  â–  (please print) APPLICANT ADDRESS â–  â–  â–  A. INITIAL APPLICATION B. CHANGE OF CAPACITY C. CHANGE OF LOCATION E. CHANGE OF OWNERSHIP F. CHANGE WITHIN CORPORATION G. OTHER (E.G., TODDLER OPTION, D. CHANGE OF FACILITY TYPE STATE CITY COMBINATION CENTER, ETC.) ZIP CODE AREA CODE/TELEPHONE ( 4. APPLICATION FILED BY:.

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