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Name: <br />Address: <br />Starting Date: <br />Number Years: <br />Individual to Contact: <br />Phone Number: <br />I certify that the information supplied herein (including all pages attached) is correct and <br />that neither the applicant nor any person (or concern) in any connection with the <br />applicant as a principal or officer, so far as is know, is now barred or otherwise declared <br />ineligible by any public agency from bidding for furnishing materials, supplies or <br />services to any agency thereof. <br />Signature of. p son authorized to sign this application <br />Name and TAle of person signing (please type or print) <br />S`-a0 <br />e/ <br />ao <br />F -11 <br />A� number 4 <br />