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<br />-5- <br /> <br />4. I understand that statements in the application are being made under penalty <br />of perjury and that false statements made herein are punishable as a Class 1 <br />misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Signed and dated this °~-day of GG~«;~.-~a~ /99~ <br />-~ <br />~~ <br />Applicant/Operator <br />By: <br />Title: <br />State of ~~ c~e~~o ) <br />ss. <br />County of ~~C^ ~ ~=~k-~ ) <br />If Corporation Attest (Seal) <br />By: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this~"~day of ~`~"`~ , /9 9%/ <br />Notary Public <br />My Commission Expires: fD-/~- 9S <br />2823E (02/05/93) <br />