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GENERAL APPLICATION FOR CERTIFICATE PART I PERSONAL INFORMATION Print all information in blue ink and in uppercase letters. LAST NAME FIRST NAME SOCIAL SECURITY NUMBER MI GENDER BIRTH DATE Month-Day-Year - Required ADDRESS Street ONLY no P. O. Box Apt. City State Zip Code FORMER LAST NAME S Required PHONE Home/Cell Race/Ethnicity Work Optional E-MAIL ADDRESS 1. Native American 2. Asian/Pacific Islander 3. Black 4. White 5. Hispanic 1. Have you ever been convicted of any crime excluding mino ...

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