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Get ed170 form 2019-2024

REV. 9/19 Enclose a NONREFUNDABLE application fee of $50 in the form of a money order, cashier s check or certified bank check payable to: Treasurer, State of CT (NO personal checks or cash accepted). GENERAL APPLICATION FOR CERTIFICATE PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.) LAST NAME FIRST NAME SOCIAL SECURITY NUMBER MI GENDER BIRTH DATE (Month-Day-Year) - Required ADDRESS (Street ONLY no P.O. Box).

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