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<br />The following information is requested to process your application. <br /> <br />Name: <br />Address: <br /> <br />City/State/Zip: <br /> <br />Roseville Resident: <br /> <br />Years <br /> <br />Home Telephone: <br /> <br />Work Telephone: <br /> <br />Home Fax: <br /> <br />Work Fax: <br /> <br />Home Email: <br /> <br />Work Email: <br /> <br />May we contact you using your work email or fax: Yes <br />No <br /> <br />Signature of Applicant Date of Application <br />