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Get CA OPOS 13B 2012-2021

4 PART A (Please Print) CANDIDATE’S NAME (Last, First, Middle) GENDER MALE APPLICATION NUMBER ADDRESS (Number and Street) SOCIAL SECURITY NUMBER (Last 6) City State FEMALE BIRTHDAY (Month, Date, Year) Zip Code DAYTIME PHONE “Yes” answers to questions in parts B and C must be explained in Part D on the back of this form. PART B 1. 2. Do you have a physical or mental impairment or disability that limits one or more of the following major life activities? YES NO YES NO YES NO a. C.

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