BER: ( ) ADDRESS (Permanent mailing address for first applicant on list) (if P.O. Box Is used. physical Number and street' Co \ OO Kt 01;) ta4 CI CAC (QAT( ' . address must also be shown.) B3 i a Rural Route: P.O. Box: CITY SF •Thin 0 YnCt C '' STATE 0 S \/ ( ZIP CODE OO ZO 0