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Get NY DS-872 2011

St Name M.I. Street Address Date of Birth (Month/Day/Year) City Client/License ID Number (from Driver License) State Class of Driver’s License Endorsements State Zip Code Restrictions Expiration Date CARRIER INFORMATION Carrier/DBA Name Legal Name (if different) Federal ID Number Street Address City Were you involved in ANY motor vehicle accident(s) during the past 12 months? o YES Information section below: ACCIDENT INFORMATION (if additional space is needed, use the back of .

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