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| First Name: | |
| Middle Name: | |
| Last Name: | |
| Address: | |
| City: | |
| Full Zipcode: | |
| Driving Class: | |
| Restriction Codes: | |
| Endorsement Codes: | |
| Height (Ft.): | |
| Height (In.): | |
| Weight (lb.): | |
| Year (Birth): | |
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| Day (Birth): | |
| Year (Issued): | |
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| Gender: | |
| Eye Color Code: | (unused in some states) |
| Hair Color Code: | (unused in some states) |
| Internal Indicator: | (unused in some states) |
| Organ Donor: |