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Ww.dmv.ny.gov CERTIFIED EXAMINER INFORMATION Driver s Last Name Street Address First M.I. City Client/License ID Number (from Driver License) State State Date of Birth (Month/Day/Year) Zip Code Class of Driver License Social Security Number County Endorsements o Male o Female Telephone Number Restrictions Expiration Date INSTRUCTIONS Check the box(es) that apply, and complete only the corresponding section(s) on pages 1-3. The examiner must sign the Affirmation section on pa.

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