Application For Authority Template Page 2

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SEVENTH
:
The name and address and,
(Attach the appropriate certificate(s) from the licensing authority.)
where applicable, the New York State license number of each professional within the foreign
professional service limited liability company that are licensed to practice the profession or
professions in New York State are:
X
Capacity of signer
:
(Check appropriate box)
(Signature)
Member
(Type or print name)
Manager
Authorized Person
Page 2 of 3
DOS-1369-f-l (Rev. 06/12)

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