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Agency Name Date 2. Agency Address Street 3. Agency Phone City State Zip Agency License Number 4. On I informed the applicant of C. G*S* 29-156a PI or 29-161q SO. Day/Month/Year Signature of Licensee or Designee Print Name/Title SO Identification Card Employee Information 5. Name Date of Birth LAST FIRST MIDDLE 6. Resident Address Telephone 7. Birthplace Race 8. U* S* Citizen Yes Sex Hgt Wgt. No Alien Reg* No* If Naturalized Where This information is only required if registration is as a Privat ...

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