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S) Name And Address Of Applicant Race Sex Height Hair Color Eye Color Weight Date Of Birth G.S. 20-179.3 Drivers License No. And State Date Of Offense Social Security No. Date Of Conviction NOTE: THIS IS A CIVIL ACTION. Use this form when the applicant's license is revoked because of a conviction in another jurisdiction substantially equivalent to impaired driving under G.S. 20-138.1. FINDINGS Upon application of the applicant for a limited driving privilege, the Court finds that:.

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