HomeMy WebLinkAbout0818 ~
,
. .
' ~
,
s o~
~ w
~ ~
~9 ~ ~
~'h0
v
' ~ ?-o ~
~ W ~
~~6Uy,
°u~a'" n;
s~~WUw 1 ~ ~ 1 i `
~iW~ ~ ~~.GI°L. r ~r~i'~.~1-~ ~ b`l~ln .
~N To che Clerk of the Circuit Gourt of , --Cou°ty. I M
~ NAML OPCOUNTY NAMB ~
~ ~ 3~11 So, C~c~~ Dv, ~p~ ,~'3 ~ ` , Q~_;_~
; on the~-- i
OI..1:.~ ~ie ~Gr_ ~c ~~e~o. Durll ( ~ ~ ~ 1 h H A-4- ~
l
ADDILS3
~e~,~~A~ Co11~,e o~ 1;~a~~~'~_ dace_~``1a ~ ~4
d~y of~~=-'~~!~, 6r~dwced ac ~p ~
Mho bein dul sNOrn, ~y:, I ~m the pecwn n~me~l in the foregoing licenu and the person nsmcd in the d.iploma ~
8 Y ~ ~
Mhich I d'aplayed before the Flor;da State Board of Dentiatry, ~nd am the laaful pos+ea~or of s~me. I have, befose ~
receivin tha liante, complied Mith all the requiremenu to the examination required by l~a: thu na money h~s i
8 I
been paid for such license, except the regular fa paid by all applicanta, and thu no fraud, murepraentac~un, or '
. mut~ke in any miterial reg~rd aas employe~ by any one, or acurred in order that such licenu should be gnnted• ~ ~
t
$igned ~ I
~
, ~ ,
COUNTY OF ~
I
~ 1
$TATE OF
' ~19~' :
Signod uid ~?orn co before me th' day of
CIe~R ~
fficer ~ ~ f h'
~ Signuure of 0 /1- , ~ d ~ ~ ~ t'''~~
~ l~?~ , ~~~1~?~' ~ ~
~ ~ 4 a
~ , [n
G .
' Lr 1 r
~~,.Ji`,~, • ,f+•`M1~~ rcl .
~ 1d, ~.~w..~ ~
. .'~i
' ,II'I''/I+/'r. •1'^r
~ ' 'j
~
~
~m~~l~l~