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PADDLESPORT RISK MANAGEMENT, LLC 121 PULASKI ROAD

KINGS PARK NY 11754 MARIA LIQUORI

631 269-9696 631 269-9656 Paddlesports@jacka-liquori.com

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Paddlesport Risk Management, LLC 121 Pulaski Road, Kings Park, NY 11754

Check: Please make check payable to: Paddlesport Risk Management, LLC DEBIT

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Online: www.paddlesportriskmanagement.com ref: Your Business Name PAYMENT OPTIONS Payment must be submitted with application