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To the Clerk of the Circuit Court of County, I 1~~ °Y`" ~ a"
NAME OP COUNTY ~ A~ ~
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~ e.n-.a~.~.~. `'1 l ~ ~ • ; OA iE1!_ ~ ~ ~ ~
~ a,f~ o a,,~,u a ~ P,~...~ born a?. ~A ~
ADDRESS J~`~' ~
raduated ac o.~-~ ~ Qas ~ L w.3 r~„a~.t_~.~ d~te ~ 7~) ~
d.1y of 8
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rwho, being duly sworn, s~ys, I am the person named in the foregoing license and the person named in the diploma ~
Mvhich I d'uplayed before the Flotida St~te Bosrd of Dontistry, and ~m the laaful possessor of s~me. I have, before ~ ~
raeiving this liunse,,wmplied with ~11 the requiremenu to the examin~tion required by law: thu no monoy has ±
been paid for such licenx, except the regular fa paid by all ~pplicants, and that no fraud, misrepresentation, or ~
I mut~ke in any m~terial reg~rd wu employed by any onc, or acurred in order that such license should be granted. ~
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i Signed '
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COUNTY OFr
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~ $TATE OF ~
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~ ,u, 19~
$ianed and sworn to before me th~~ ~ 9 day of - '
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~ Signature of Officer °A";R ~tRlc
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