P.O. Box 41395, Washington D.C. 20018
yorubaalliance.org
1. Business Name: _______________________________________________________
2. Contact Name: ________________________________________________________
5. Telephone: ___________________________________________________________
6. Address: ____________________________________________________________
7. City: ______________________________________________________________
8. State: _______________________________________________________________
9. Zip Code: ______________________________________________________________________
10. License Number: ________________________________________________________
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12. Declaration:
I___________________________hereby declare that the above information is given in
good faith and to the best of belief. I further declare that the Organization should use these
informations in its administration.
13. Signature & Date: ____________________________________________________
Please do not write below this line.
14. Official Use Only:
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