... [Name of Licensee] .................................................................................
... [Address of Licensee] .............................................................................
STATE OF NEW YORK | } |
} | SS: |
COUNTY OF................. | } |
_____ of _____ being duly sworn, says that he is ___ of the publishers of the _____, a (daily) or (weekly) newspaper (printed and) published in the (city, town, or village and county) _____, and that the notice of which the annexed is a true copy, has been published in said newspaper for two successive weeks commencing on the ___ day of ___
... __________ ..........................................................................................
Sworn to before me this day
Of _____,
N.Y. Comp. Codes R. & Regs. Tit. 9 § 104.1