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R may reproduce it on word-processing equipment. If the application is reproduced, please use the same size and format and repeat verbatim on the application every question or category on this form. 1. Please provide your full name and birth date. 2. Please provide your home address, telephone number, and email and, if applicable, your office information. 3. Please provide your attorney number and indicate whether you are on active status with the Indiana Commission on Continuing Legal Educ.

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