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To ihe Clerk of the Circuit Court of ' Y~
NAME OFCOUN7Y NA
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of /SGS C°~~.. GE~ .~t~`. i'~~ , born at~ ' 1''"''°' , on the~~ ,
ADDRESS .
~ ~ d~ of graduated at.l~S-~. ~ ~:...y,~.~.~dau ~ / a ,
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who bein dul saorn, s~ys, I ~m the perwn named in the foregoing license and the person named in the diplom~ ~p ~o TAO~>
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I ' which 1 displ~yed before the Florido $tate Board of Dentistry, and zm che l~af ul po~sessor of s~ne. I.have, before D,~o
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' receiving this license, complied with ~ll the requiremcnts to the ex~min~tion requircd by I~w; th~t no money h~s ~ ~~ogA
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Cp bten p~id for such licenx, except the rcgular fa paid by ~Il aQplic~nts, ~nd that no fr~ud, misrepresent~tion, or ~ o;~o
~ ~ mutake in any materi~l regard was employed by ~ny one, or occurred in order chat such license should be granced, iJl
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~ , ~ Signed
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COUNTY OF ~
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S7ATE OF '
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day of , t9,C.9 I ~
Signed ~nd sNOrn to before me th' '
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Signature of Of f icer ~ .
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~~w~~~~A' . NOTAR'f MllLIC ~TA1f OR RORIDA RGE ;,r,
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