Transcription of CONTINUED ON BACK - Rhode Island
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CONTINUED ON BACK - Rhode Island
TRANSACTION TYPE (SELECT ONE)LICENSE(complete sections A, B, C, D, E*, F*G)A. APPLICANT S INFORMATION (COMPLETE ALL FIELDS)TELEPHONE:SUFFIX:RI DRIVER S LICENSE # / ID # / PERMIT #:DATE OF BIRTH: (MM/DD/YY)GENDER:SOCIAL SECURITY NUMBER:HEIGHT: : COLOR:COUNTRY:STATE/PROVINCE:CITY:CONTIN UED ON BACKC. PHYSICAL INFORMATION (COMPLETE ALL FIELDS)D. GENERAL QUESTIONS (COMPLETE ALL FIELDS)NEWPASSPORT / EMPLOYMENT AUTHORIZATION / RESIDENT ALIEN CARD #:MALEFEMALEDo you want to register as an organ and tissue donor?ACTIVE MILITARY:100% DISABLED VETERAN:YESNOB. PLACE OF BIRTH (COMPLETE ALL FIELDS)Pursuant to RI Gen.
minor law chapter 31-10 of the general laws of rhode island, 1956 as amended. certification by parent(s) or such responsible person as indicated in chapter § 31-10 for a minor under 18 years of age.
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