PD153-CS 96011596/G[/I0
2~ PLdrweT aid,
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~O'd
Fail~ro to erL-'t lbo sift at 1~ tcu (10) dip pdo~ to the Plnf~iol Comm~ton ~ w~ll msulz il
posq~nemtn~ of die ~)oinf cuo M~til this ~ndidou is nmL
A deposit in me amount of ll,~y iSoli~rs (S60.O~y) will bo rsquired orb a~pJicant w~.en h.? .or she_
~O'd £6t~-7./c3-t,]:~ Ll:)a:~o~nv L~uo.L~eN d0t~:~O 96-~[-ue~'
ACCOUNT
Ar¢OUN1'
~AMT. PAID.
CASH
RECEIPT
~eceiYed From
Adclress
0030505
,or'~<'~ ~ ~ .,,~-,:, ~,, ~ ~.~.~
HOW PAID
ACCOUNT ~
DUE ~DER