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S WILL BE USED TO MAIL YOUR FORM BACK TO YOU. First Name, Middle Name, Surname Unit/Number, Street City, Province Postal Code DATE OF REQUEST (yy/mm/dd): Reason for Request: Verified by: Maiden Name: Other Names Used: Date of Birth (yy/mm/dd): Place of Birth: Home Telephone Number: Sex: M F I hereby certify that the information provided above is true and correct to the best of my knowledge and belief. I hereby authorize the Ottawa Police.

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