Get CT Q-12 2001-2021
DER THE LICENSE ISSUED TO ME BY A FOREIGN STATE FOR THE REASON GIVEN BELOW. NAME DATE OF BIRTH CONNECTICUT ADDRESS NAME OF FOREIGN STATE ADDRESS ON FOREIGN STATE LICENSE REASON FOREIGN STATE LICENSE CANNOT BE SURRENDERED: I DECLARE UNDER PENALTIES OF FALSE STATEMENT, THAT THE STATEMENTS MADE ABOVE ARE TRUE AND CORRECT. SIGNATURE OF OPERATOR X DATE SIGNED .
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