- Check boxes that apply:
- Are you a U.S. Citizen?
Are you at least 17 years of age? (If No, DO NOT complete this form)
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Please fill in the following fields:
First Name:
Middle Name or Initial:
Last Name:
Suffix (Jr., Sr., III):
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Date of Birth:
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NJ Driver's License Number or MVC Non-Driver ID Number:
If you DO NOT have a NJ Driver's License or MVC Non-Driver ID, provide the last 4 digits of your Social Security number.
"I swear or affirm that I DO NOT have a NJ Driver's License, MVC Non-driver ID or a Social Security Number."
- Home Address: Apt. Municipality: State: Zip Code:
- Home Address: Apt. Municipality: State: Zip Code:
- Home Address: Apt. Municipality: State: Zip Code:
- Former Name if Making Name Change:
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