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SOCIAL SECURITY NUMBER AFFIDAVIT PLEASE TYPE OR PRINT Applicants who do not have a social security number to submit to the IDFPR must complete this form. 1. LAST NAME FIRST NAME MIDDLE NAME 2. DATE OF BIRTH / / Month Day Year 3. ADDRESS (STREET, CITY STATE, ZIP, COUNTRY) Disclosure of your U.S. social security number, if you have one, is mandatory, in accordance with 5 Illinois Compiled Statutes, 100/10-65 to obtain a license. The social security number may be pro.
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