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IFICATE SECTION I Application is hereby made for the following: $80.00 fee New Application SECTION II General Information: Name: Address: City: State: Telephone: Hair: Zip: Drivers License Number: Eyes: Height: Weight Have you taken the exam within the past 15 days? Have you ever held a Weekly Fire Pump Test Certificate? If so, was your Certificate denied, revoked, or suspended? If yes, please explain: DOB: No No Yes Yes Date: FP: No Yes SECTION III Employer Information: Name: Add.

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