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Icense Number Action Requested Change Business Name and/or DBA ($10.00) Change Location same county ($10.00) Current Business Name Current Business Phone Current Trade (DBA) Name (if applicable) County ( Current Business Address ) City State Zip New Business Name New Business Phone (if applicable) New Trade (DBA) Name (if applicable) County ( ) New Business Address (must be in same county) City State Zip Mailing Address City State Zip Licensee/Owner/Officer.

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