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1.GUNDERSENPatient Name: ___ Former Name(s): ___ Date of Birth: ___ Address: ___ Phone Number: ___ Medical Record Number (if known): ___HEALTH SYSTEM1900 South Avenue, AVS001, La Crosse, WI 54601

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Start by writing the day of the month you were born in the first box.

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Move on to the second box and write the month you were born in.

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Lastly, write the year you were born in the third box.

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Organizations that require age verification such as government agencies, employers, schools, and healthcare providers may need your date of birth address.

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What is date of birth address?

Date of birth address refers to the specific location where an individual was born.

Who is required to file date of birth address?

Individuals are required to file their date of birth address when applying for official documents or for identification purposes.

How to fill out date of birth address?

To fill out a date of birth address, one must provide the city, state, and country where they were born.

What is the purpose of date of birth address?

The purpose of a date of birth address is to provide accurate information about an individual's birthplace for official record-keeping purposes.

What information must be reported on date of birth address?

The information that must be reported on a date of birth address includes the exact location where the individual was born, including city, state, and country.

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