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City, AZ 86403 PH: (928) 453-4146 FAX: (928) 855-5327 EMAIL: cscounter lhcaz.gov OWNER NAME MAILING ADDRESS BUSINESS NAME / DBA Last First Middle AZ RESALE TAX # BUS. TEL. MOHAVE CO. HEALTH # DESCRIBE BUSINESS Sole Ownership Partnership Corporation: State: Name: PRINCIPAL / OWNER NAME Title Home Address City / State PRINCIPAL / OWNER NAME Title Home Address City / State EMERGENCY CONTACT Phone Zip Driver's License # State Phone Zip Date of Birth Date of Birth Driver.

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