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Get CA LIC 041-A 2023-2024

(Type or print clearly) 01 License Type (chose one only): 02 Name: Last Name 5 6 Check One: 011 013 Insurance Adjuster (Independent) (AJ) Public Adjuster (PJ) ** Crop Insurance Adjuster (CR) InterimInsurance Public Insurance Adjuster (PI) (Residents Only) 4 Birthdate mm/dd/yyyy First Name Full Middle Suffix 3 Male 0 California Resident Female Nonresident: (Non-resident is not available for Interim Public Adjuster) Identification Information: Social Security Number (S.

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