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Get IL DSD X 20.14 2018

S Driver’s License Number Street Address City Reset Birth Date Month ZIP Code Day Year Gender ❏ M ❏ F Telescopic Readings On Reverse I authorize release of the report of this examination to the Secretary of State, Driver Services Department, Springfield, IL, for confidential use on my driving record. This report is valid for six (6) months from the examination date below. ___________________________________________________________ ___________________________________________.

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