Request To Place License On Inactive Status


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License Details



Signature and Certification

Your signature below certifies that you are directing the Commission to place your license on Inactive Status.

(Type your name)

Date Signed

12/18/2017


Info
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Info
Processing Form...
107.20.115.174

This form is not meant to be printed. If you have already completed the form please use the submit button at the bottom to send the form directly to the Commission.