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PREPARE AN ORIGINAL AND TWO 2 COPIES PROCEDURE TO COMPLETE THIS FORM 1. Enter your business name as submitter and mailing address Registration service and or dealer/ dismantler number. Print the name and telephone/FAX number of the representative responsible. 2. Indicate choice of refund or credit media if you have overpaid. Original this copy will be retained by the department. 3. When list is completed indicate choice of picking up the list or having the list mailed. First Copy due him after ...

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