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Less than 3 years) (No., Street, City, State, Zip Code) (No., Street, City, State, Zip Code) Telephone Number(s) (include Area Code) Judge Name US Attorney Name Sentencing Date Defense Attorney (Name, Address City, State & Zip Code and Phone or attach Business Card) Your Offense Sex Race Weight Hair Color Eye Color Date of Birth Place of Birth Citizenship Social Security # Immigration # Driver's License # Issuing State Have you ever been convicted of a crime, including DUI/DWI.

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