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Get CT ED 170 2012

EFUNDABLE application fee of $50 in the form of a money order, cashier’s check or certified bank check payable to: “Treasurer, State of CT.” (NO personal checks accepted). GENERAL APPLICATION FOR CERTIFICATE PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.) LAST NAME FIRST NAME – MI – – GENDER (M/F) – BIRTH DATE (Month-Day-Year) – Required SOCIAL SECURITY NUMBER ADDRESS (Street) (City) FORMER LAST NAME(S) .

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