Personal History Disclosure Form Page 4
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4I certify that the information contained in this Personal History Disclosure Form is accurate and true to the best of
my knowledge.
’
: ___________________________________________________ D
: _______________
Before me this _____ day of _______________________, 20___.
Notary Public:_______________________________________
My Commission Expires: _______________
Notary Seal, if available
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Regional Offices – Barre/Essex Jct./Rutland/Springfield/St. Johnsbury
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