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Get Lic34 Form 2013-2024

Include Driver License NAME TYPE LIC./CERT. /REG. NUMBER STATUS (active / not active) EXPIRATION DATE Select One Select One Select One  Yes  Select One No Have any licenses/ certifications/ registrations issued to you ever been suspended, restricted, or revoked; or have you ever been censured or disciplined in connection therewith? If Yes, please indicate in Section 7 the type of license / certification / registration along with the reason for suspension, restriction, or revocat.

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