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Get Application For A Limited License To Participate In A ... - State Of Indiana

Om W072 Indianapolis, IN 46204 Telephone: (317) 234-2064 E-mail: pla5 pla.IN.gov State Form 50318 (R2 / 2-06) Approved by State Board of Accounts, 2006 * Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. FOR OFFICE USE ONLY DATE RECEIVED (month, day, year) FEE AMOUNT RECEIVED APPLICANT RECEIPT NUMBER Attach one (1) passport-quality photograph of yourself here. FEE IN.

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