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City /State /Zip: Phone: ?'y Fax: <br />E -mail: <br />Signature: Date: (o j L Z 013 <br />REPRESENTATIVE (If different from Surveyor): <br />Name (print): - "i � A : : A V&A <br />Company /Organization: <br />Address: `/0 ) A�t'✓ <br />City /State /Zip: j �/v �,i� Phone: 6 ,e3 70�Ej Fax: <br />E -mail: <br />�JZ u G Nqs . C41tl <br />Signature: <br />/ Z/?0 1 <br />"Attached additional sheets if necessary. <br />Annexation Last Revised May, 2009 Page 4 of 4 <br />Application Form <br />