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AND REQUIRED $30.00 FEE TO THE: LOUISIANA MOTOR VEHICLE COMMISSION 3519 12TH STREET, METAIRIE, LOUISIANA 70002 Check Amount $ Name of Lessor Agent (Hereinafter referred to as Applicant) Social Security Number Lessor Agent License No. (If applicable) Date of Birth State Driver s License was issued Driver s License Number Parish/County State Zip Code Physical Residence Address of Applicant City Name of Motor Vehicle Lessor (Hereinafter referred to as Employer) Physical Address of.

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