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(1900 Capitol Avenue) Street No. Contact Name (Mandatory for all school submissions) Street or PO Box Sacramento, CA 94244-2700 City State Name of Applicant: (Please Print) (916) 445-7254 Contact Telephone No. Zip Code Last MI First AKA s CDL No. DOB: Male SEX: Female Misc No. BIL - Agency Billing Number (if applicable) HT: WT: Misc. No. EYE Color: HAIR Color: Home Address: (Applies only if Youth Org/HRA or Public Utility submission) POB: Street or PO Box SOC: City.

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