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	License Ever Suspended/Revoked?

	SR22 Required?


	First name:

	Last name:

	Gender:

	Date of birth:

	Marital Status

	Current Residence:

	Years lived there:

	Years In Field:

	Occupation:

	Education:

	Credit Rating:

	Currently Insured?

	License Status:

	License State:

	License Ever Suspended/Revoked?

	SR22 Required?

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