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Clude personal information.) I, , hereby certify that I granted access on this one occasion to my Driver License/ID Card record, inclusive of the personal information (name, address, driver identification number, etc.) to Signature of License / ID Card Holder or Parent / Legal Guardian . Date State and Federal Law Requires Requestors to Agree to the Following: In requesting and using this information, I acknowledge that this disclosure is subject to the federal Driver s Privacy Protection.

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