Form Dos-1369-F-A - Application For Authority Page 2
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3SEVENTH
: The name and address and, where applicable, the New York State license number of each
professional within the foreign professional service limited liability company who is licensed to practice the
profession or professions in New York State is:
.
X
Capacity of signer
:
(Check appropriate box)
(Signature)
Member
Manager
(Type or print name)
Authorized Person
Page 2 of 3
DOS-1369-f-a (Rev. 03/17)
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