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❑ Mr. � Mrs. First Name <br />❑ Ms. ❑ _ CHERI <br />Title <br />MAIN STREET MANAGER <br />' Secondary Phone (optional) <br />� ( ) - Ext. <br />W E-mail address <br />Vcbedford@paristexas.gov <br />� <br />Address <br />135 S. E.1 ST STREET <br />City <br />PARIS <br />M. I. Last Name <br />BEDFORD <br />Primary Phone <br />(903) 784 - 9293 Ext. <br />Fax (optional) <br />(903) 785 - 8591 Ext. <br />Would you prefer to be contacted by E-mail? <br />� Yes ❑ No <br />State Zip <br />TX 75460 <br />County <br />LAMAR <br />The applicant, by and through its agenYs signature below (1) certifies that all information provided in <br />connection with this application at any time is true and correct to the best of their knowledge; (2) <br />acknowledges that any misrepresentation or false statement made in connection with this application, <br />whether intentional or not, will constitute grounds for denial, pursuant to this application and/or <br />assessment of monetary administrative penaities. If signed by an agent (including employee) of the <br />applicant, the person signing certifies that he or she is authorized to make the preceding certifications on <br />behalf of the applicant. <br />Chief Elected Official (type or print name) <br />ARJUMAND HASHMI <br />Appficant Signature <br />Title <br />MAYOR <br />Date / / <br />month day year <br />2010 Main Street Application Page 8 of 30 2-5-10 <br />