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How to fulfill the information to get my lisence, thx so much

hawk2001_2002
Beginner
Beginner

                   Hi Experts

I have a problem about getting my lisence

未命名.jpg

I have no idea that what i should fill in the second blank, and I think the words on the left is just a statement, can anybody help, thx so much!

Regards

Haohong

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