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CITy STATE DATE of BIRTh (MM,DD,YYYY) ZIp CoDE RESIDEnCE ADDRESS (If DIfferent froM MaIlIng aDDress) CITy STATE DAyTImE TELEphonE numBER ( CALIfoRnIA DRIvER LICEnSE/IDEnTIfICATIon CARD numBER ZIp CoDE SoCIAL SECuRITy numBER ) SECTION 2 CERTIFICATION I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. AppLICAnT SIgnATuRE DATE X AUThORIZATION all records of the department relating to the physical or me.

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