DATE 12- 1543 OL in OR DEALER s mi l l i X g PRINT NAME SIGNATURE A DATE OL. ID OR DEALER I 1 1 1 1 1 1 1 PAINT NAME SIGNATURE X DATE IL ID OR DEALER 0 I I I I I I I HARING ADDRESS CITY STATE 6100 RED HOOK OUATERS B-3 ST THOMAS, VI 00802 DAYTIME PHONE I 212 b91-6414 SELLER