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Lic41 2016
Name:
First Name:
MI:
Mailing Address:
State:
Zip:
City:
**Social Security Number:
Date of Birth (MM/DD/YY)
Telephone Number:
Class: A
B
*Email Address:
*Applicants must enter a valid email address. Notification to schedule your exam will be sent via email.
DISCLAIMER: Please be aware that all applicants will be allowed to take the practical examination before they are
found qualified for the license by the Department. It is solely the applicant’s responsibility to ensure that he...
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