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To the Gerk of the Circuit Court of County. I, Lp
NAME F COUNTY NAME I~~~ ~
' Q,e.,,,.z~. l , ,~-k "11 ~
of ' ~ , born at ~ on che i
A ~EU ~ I~~ ~1
~ ~ raduaced ac ' date ~ ~
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aho, being duly sworn, s~ys, I am the person n~med in the foregoing license and the person named in the diploma
~ ~ which I displnyed before the Florida 5tate Boud of Dentistry, and am the l~wful posseuor of same. I.have, before ~
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receiving this license, complied with all the requiremcnts to the ex~mination required by Iaw: that no money has ~ ~
, been paid for such licenx, except the regular fa paid by ~ll applicants, and th~t no fr~ud, misrepresencuion, or w!
mist~ke in ~ny mueriZl regard was employed by any one, or occurred in order th~t such license should be granted. ~ i
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COUNTY OF P
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STATE OF ;
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Signed and s~vorn to before me th~~d~Y of ,
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