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(800) 655-4845 or (919) 572-6880 Please type or print clearly in black/blue ink all the following information. Be sure to sign the Statement of Affirmation. Last Name NOTE: This form must be mailed and postmarked by the deadline shown below. First Name Middle Name Social Security Number Exam Date: August 29, 2013 Postmark Deadline: June 1, 2013 - -.

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