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Begin by selecting whether you are a new applicant or renewing your license. Fill in the most recent License to Carry/FID Number if applicable.
Complete the personal information section, including your last name, first name, middle name, and suffix. Ensure that your residential address is accurate.
Provide your date of birth and place of birth. Fill in details about your parents as required, including their names and any relevant identification numbers.
Answer all questions regarding citizenship, previous names, age, and any criminal history accurately. If you answer 'YES' to any questions from 4-14, provide detailed explanations.
List two references with their names and addresses. Finally, review all information for accuracy before signing the application under penalties of perjury.
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Jul 19, 2005 Please note that the certification statement is on the back of the form. PROVIDER IDENTIFICATION NUMBER (Field 25A). The Medicaid Provider IDRead more
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