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Me applicant, enter start date of activity that requires this license. Renewal Applicant If renewal applicant, enter account number/NCDOR ID for this license. Part 1. Professional Individuals First Name M.I. Last Name Social Security Number Daytime Phone (Include area code) Name of Business Where Professional Individual Is Employed (optional) Address Where License Is To Be Mailed (This address is printed on the license.) City State Zip Code (5 Digits) County Enter Code Number and Lic.

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