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