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  2. Applicant Information:
  3. State License Information:
  4. Type of State License or Registration (please check all that apply)
  5. Signature Authorization
  6. The following individuals are hereby authorized to obtain permits or sign documents for the above named company. (When you decide to add another person’s name to the list at a later date, you must either send a written letter or sign the form yourself allowing that person to pull permits under the company’s name).
  7. Leave This Blank:

  8. This field is not part of the form submission.