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Get Or 735-6776 2018

SS (IF DIFFERENT FROM RESIDENCE) CITY STATE ZIP CODE STATE REASON YES DATE NO CURRENT OR PREVIOUS MILITARY SERVICE: By checking this box I authorize DMV to send my name and address to the Department of Veterans Affairs (ODVA) for the purpose of receiving benefit information. DO YOU CURRENTLY HAVE, OR HAVE YOU EVER HAD, YOUR LICENSE OR PERMIT TO DRIVE OR RIGHT TO APPLY FOR THE PRIVILEGE SUSPENDED, REVOKED OR REFUSED? You are required to report any mental or physical condition or impairme.

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