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<br />-5- <br />4. .[.understand that statements in the application are being made under penalty <br />of per;~ury 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 a~sr day of <br />' / ~G %~~; <br />~~~ ~~ <br />Applicant/OFl,~ratar <br />By: ~//7.~ac~ ~Cj'~ v~~ <br />Title: <br />If Corpor tion Attest Seal) <br />;' . <br />ey: ~~~~~ ~~~: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />' State of ~~ G' ) <br />ss. <br />County of ~?i~/tea/' ) <br />The foregoing instrument was acknowledged,pefore me thls~~da of ~ 1 y~ <br />by , Q.,l i~!` ,S . ~- as ~j~eE+ A~ts~a'~~=_ ~ of {'~I I <br />ry PulSlic <br /> <br />My Commission Expires <br />/ 3 c5 - <br />(04/92) 2823f' <br />