First Name: Middle Initial: Last Name:
Male Female
Date of Birth: Social Security Number:
Indicate Preferred Mailing Address: Home Business
Address: City, State Zip: , Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other / Canada Phone: Email:
Company: Address: City, State Zip: , Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other / Canada Phone: Email:
On (date) I requested CLARB to submit my national council record and LARE test results to North Dakota. I understand no action will be taken until my council record, LARE test results and the license fees of $210.00 are received by the North Dakota Board.
Other than traffic violations, have you ever been convicted of a felony or misdemeanor? Yes No If the answer is “yes” to the above question, please provide details including results of any appeal on a separate sheet of paper.
AFFIDAVIT I declare and affirm under the penalties of perjury that this application has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. Submittal of this application serves as my signature.
