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BOARD OF ELEVATOR AND TRAMWAY SAFETY - Maine.gov - Maine
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GAL NAME MIDDLE INITIAL LAST ANY OTHER NAMES EVER USED: DATE OF BIRTH mm / dd / yyyy SOCIAL SECURITY NUMBER - - MAILING ADDRESS CITY STATE PHONE # ( ) FAX # ( ZIP ) COUNTY E-MAIL CRIMINAL BACKGROUND DISCLOSURE NOTE: Failure to disclose criminal convictions may result in denial, fines, suspension and/or revocation of a license. 1. Have you ever been convicted by any court of any crime? (circle one) NO YES If yes, enclose a detailed description of what happened (including dates) and.
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