Transcription of DRIVER'S LICENSE AND IDENTIFICATION CARD …
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DRIVER'S LICENSE AND IDENTIFICATION CARD …
NOTE: YOUR ADDRESS BELOW MUST BE CURRENT. THE POSTAL SERVICE WILL NOT FORWARD YOUR LICENSE OR ID NUMBER (optional)GENDER (check one) FEMALEMALEWEIGHT OF CITY OR COUNTY OF RESIDENCE COUNTY OFCITYSOCIAL SECURITY NUMBER (SSN)BIRTHDATE (mm/dd/yyyy)FULL LEGAL NAME (last, first, middle, suffix)EYE COLORHAIR COLORIF YOUR NAME HAS CHANGED, PRINT YOUR FORMER NAME HERE APPLICANT INFORMATIONSTREET ADDRESS APT NO. CITY STATE ZIP CODEHEIGHT FT.
2. Do you have a physical or mental condition which requires that you take medication? If yes, please list the condition(s) and the name of the medication(s).
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