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Nom, Name

Prenom, First Name

Date et iow de naissance,

Date and place of bith

Dalivee le, Date of issue

Expire le, Date of expiry

Dalivre par, issued by

Ne permis, Licence number

Depuis te, Vata from

‘Jusqu'au, Vaid to

Codes. Codes

12.

i Aan iLt

iO 10. 12.

re Ga seosssasenses] oonanesensens vansansnnean

15-11-2001] 16-03-2033 T7"

i 10-09-2003] 16-03-2028 ="

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