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ERSHIP / ASSOCIATION, LISTED IN #2, HAS AGREED TO LEND TO: FOR THE PURPOSE OF THE ACQUISITION OF THE LICENSE, LICENSED BUSINESS, REAL ESTATE, EQUIPMENT, FIXTURES, COMMON OR PREFERRED STOCK ASSOCIATED WITH LICENSE NUMBER , THE SUM OF . 2. THESE FUNDS WERE DERIVED FROM THE PERSONAL / BUSINESS ASSETS OF THE FOLLOWING INDIVIDUAL(S) / CORPORATION: NAME 3. ADDRESS INSTITUTION ACCT NO. IF FUNDS TO BE LOANED ARE CORPORATE, INCLUDE THE FOLLOWING PERSONAL.

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