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Current Address:

________________________________________________________________

Street City State            Zip Code

________________________________

County

How long at this address: ___________________________

Former Address:

________________________________________________________________

Street City State            Zip Code

________________________________

County

How long at this address: ___________________________

Former Address:

________________________________________________________________

Street City State            Zip Code

________________________________

County

How long at this address: ___________________________

Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

If NOT a U.S. born citizen: Alien No. A 0___ ____ ___ ___ ___ ___ ___ ___

Document Type (check one) I-551 ___; I-688 ___; I-766 ___

Or I-94 No. 94___ ___ ___ ___ ___ ___ ___ ___ ___

Expiration Date on Alien or I-94 Card __________________________________

Driver’s License Number: ____________________________________________

State of Issuance: _________

Driver’s License Number: ____________________________________________

State of Issuance: _________

Driver’s License Number: ____________________________________________

State of Issuance: _________

Tag No. or Vehicle ID No.: ___________________________________________

Date of Birth*: ____________________________Gender*: _________________

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