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Yes

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Yes

Have You Ever Been Convicted of a Felony?

Yes

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I certify that my answers are true and complete to the best of my knowledge.

Signature:

Date:

Haven Harvesting

Address:16057 410th Avenue Conde, SD 57434

Email:jeremyhaven78@gmail.com

Phone Numbers:

Jeremy Haven	605-228-9208
Lindsey Haven	605-968-4156

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