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ZOi�:IiVG - TJCYi'Ik`7,C�TICh OF IN1'�1VT <br /> (Checic o:�e or bcth: ) � �''arnil,y 2�'oster ��o�e <br /> � � F�i],y Day Care Home <br /> TO• �J�ar�v � � ''1 <br /> ! • (d�.unicipaluty or Political Sub-Division} S � � ' <br /> I - 335���+� <br /> (Street t�ddress <br /> S 5 3� <br /> (.i#�y) (vtate) ('Li�:) <br /> �'h�i�i: 5 5���r�� , ��c . <br /> (Cour�ty �rJel.fare Department or Voluntary A;ency) <br /> � �0 3 1�► �-t�-�o-,�ol,�.�.Z- 1� <br /> M Street Address) (`Lip <br /> I l� n�.c e���-s <br /> �it;r) ���� (State) <br /> SEIv'1' �Y: ��-�- — <br /> ��:::c !ac ;artr..cr.t Uivisicn <br /> n:'r�l(;�,..'1'• � O�'--�-�. ��r'�a�&�. <br /> �:uaj;.e) <br /> aI� � � C'.r� -�o ,�.�- �o�. . . <br /> (:itr�;e.t.j ' <br /> W �il. d--�= � ���'1 • � JC ( <br /> �Ci�y}-�� (Staf,e) (Lig) <br /> Fu,S�`:.:c� C�I,L � <br /> .�ur.�ber of Ivatunal Children ui�c'.er It� i.,i i�o:�ct (Ciz^c1e Iyt:..;���r) 0 i�3 4 S ��� <br /> i��a;:.t;er of k'o�ter Ci;i.'�dre:i inc3uded in License: �i�ircl� i:um�;er) 0 1 2 3 4 5 b ��1 <br /> r._.1 <br /> A&Y CA,`�"r: ' � <br /> rltunber of P�atural Preschool Children in iioriie: {C�.rcie IVwnber) � 0 L2 3 � <br /> iaur.�ber of D;y (:art� C:hildren in�l�ided in Licei�se: {�i;c�.e i�i�:ber) 0'1 2 � �. 5 <br /> �l S 1 S a. �.1 1 C-ec1S-e, �:�- c�.. Y�-e�--..5 � . `�S � �� <br /> 5��,�,,�..�. . � . <br /> � \ _ ' <br /> DI�TE QF i�IOTIFICATION: (?� � � � �g� <br /> �� i•.on h) llay �Ye� <br /> ��'i� 25 , <br /> � ,��....�� {, � <br /> r:";;-3"'a� f,, 4 • <br />