11A-058 (15) COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY
1 OF 1010 COMMONWEALTH AVE.
MASSACHUSETTS BOSTON, MASS.02215
ENCLOSE CHECK OR MONEY O'
1- I FOR REQUIRED FEE,
EXPIRATION DATE t} N�\� J'F+ ( '_ ,' ) L ,; V
MAGE PAYABLE TO
U / 5 9 5 s EFFECTIVE Dare uc-No. IV
RESTRICTIONS "COMMISSIONER OF PUBLIC SA'
AOAF, c/ SiT/ i ;'.1 Otthcy
(DO NOT SEND CASH).
lu F.lil ;-Fl ' itLUSZ
RT 65
SS 8 C37-34-4:'h5 HU-+TI +.bT Nq 91 091) PLF13E NOTE FEE INCPEN '
NI ENLYSTIxG am ONLY) FEE.
'IVG.O"1 9FFFCIIVF, FFd. 1 , 1535
HEIGHT LOU
STAINED ON 1111 OF NE CLOSSIANANTO
DOS:
J1 / ?,G/ 19n1 -711, , - - �• .A ➢O �JT OFTALIn LICLF[SE
S�Oy�„^C l LICENSEE SIGN NAME IN FULL ABOVE SIGNATpPE
�)�” MISSIONEP
oTN.a, NI..T muue o Eo 1, mis occYEAnoN .CIN ✓._ oM
UY
200M 20)bl<29