Find out why eFax is the leading online faxing service or find the best plan for you by calling (800) 958-2983. Fax from anywhere with our mobile app. You may make extra copies of page 17 or attach a separate sheet for additional affiliations.) General Assistance (GA). SERVICES SANCTIONS, 0028.30.04.03 - POST 60-MONTH SANCTIONS: 2-PARENT PROVISIONS, 0028.30.06 - TYPE/LENGTH OF SNAP E&T SANCTIONS, 0028.30.09 - REFUSING OR TERMINATING EMPLOYMENT, 0028.30.12 - SANCTION NOTICE FOR MINOR CAREGIVER, 0028.33 - EMPLOYMENT SERVICES/SNAP E&T NOTICE REQUIREMENTS, 0029.03.06 - FAMILY SUPPORT GRANT PROGRAM, 0029.03.09 - CONSUMER SUPPORT GRANT PROGRAM, 0029.03.18 - RELATIVE CUSTODY ASSISTANCE PROGRAM, 0029.06.03 - SUPPLEMENTAL SECURITY INCOME PROGRAM, 0029.06.06 - RETIREMENT, SURVIVORS AND DISABILITY INSURANCE, 0029.06.21 - UNITED STATES REPATRIATION PROGRAM, 0029.06.24.03 - TRIBAL TANF - MILLE LACS BAND OF OJIBWE, 0029.06.24.06 - TRIBAL TANF - RED LAKE BAND OF CHIPPEWA INDIANS, 0029.07.09 - WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM, 0029.07.12 - COMMODITY SUPPLEMENTAL FOOD PROGRAM, 0029.07.15 FOOD DISTRIBUTION PROGRAM-INDIAN RESERVATION, 0029.20.09 - FAMILY HOMELESS PREVENTION ASSISTANCE, 0029.27 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM, 0029.31 - CHILD CARE RESOURCE AND REFERRAL, 0030.03.01.01 - INELIGIBLE FOR OTHER CASH PROGRAMS, 0030.03.09 - DETERMINING RCA GROSS INCOME, 0030.03.16 - PROCESSING REPORTED CHANGES - RCA, 0030.03.18 - RCA OVERPAYMENTS AND UNDERPAYMENTS, 0030.12.03 - RCA POST-SECONDARY EDUCATION/TRAINING, 0030.12.06 - RCA EMPLOYMENT SERVICES GOOD CAUSE CLAIMS, Combined Application Form (CAF) (DHS-5223) (PDF). ® Completed forms can be mailed or faxed to the Financial Assistance Division at 218-327-5548. Chronological listing [month/year] of employment/practice history since completion of your post-graduate training. : F O R M T E X T A d m i t t i n g P r i v i l e g e s : D e p a r t m e n t N a m e : F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o D e p a r t m e n t C h a i r p e r s o n : F O R M T E X T F O R M C H E C K B O X A p p l i c a t i o n P e n d i n g A d d r e s s F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T O t h e r H o s p i t a l A f f i l i a t i o n s - P r e s e n t and past affiliations beginning with most recent. F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I f n o , l a s t d a t e o f e m p l o y m e n t : F O R M T E X T / F O R M T E X T / F O R M T E X T S p e c i a l t y / S u b s p e c i a l t y i n w h i c h c a r e w i l l b e p r o v i d e d : F O R M T E X T - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 4 . See 0005.12 (Accepting and Processing Applications), 0006 (Determining Financial Responsibility). O t h e r P r a c t i c e N a m e : F O R M T E X T P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T A d d r e s s : F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e E - m a i l A d d r e s s : F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F e d e r a l T a x I D N u m b e r ( i f d i f f e r e n t f r o m p r i m a r y ) : F O R M T E X T C r e d e n t i a l i n g C o n t a c t : F O R M T E X T P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T C u r r e n t l y p r a c t i c i n g a t t h i s l o c a t i o n ? : F O R M T E X T A d m i t t i n g P r i v i l e g e s : D e p a r t m e n t N a m e : F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o D e p a r t m e n t C h a i r p e r s o n : F O R M T E X T F O R M C H E C K B O X A p p l i c a t i o n P e n d i n g A d d r e s s F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F r o m F O R M T E X T / F O R M T E X T / F O R M T E X T F a c i l i t y N a m e : F O R M T E X T T o F O R M T E X T / F O R M T E X T / F O R M T E X T T y p e / c a t e g o r y o f p r i v i l e g e / a f f i l i a t i o n ( a c t i v e , c o u r t e s y , e t c . ) P e n d i n g F O R M T E X T F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M C H E C K B O X F O R M T E X T F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M C H E C K B O X F O R M T E X T F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M C H E C K B O X F O R M T E X T F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M T E X T / F O R M T E X T / F O R M T E X T F O R M C H E C K B O X I f n o t c e r t i f i e d , p l e a s e s t a t e y o u r i n t e n t f o r c e r t i f i c a t i o n a n d d e s c r i b e t h e s t a t u s o f y o u r e f f o r t s a n d e l i g i b i l i t y , i n c l u d i n g s c h e d u l e d d a t e o f e x a m , p a s t f a i l u r e s o f w r i t t e n o r o r a l e x a m s , i f a n y . Provide current and complete addresses. Go to ApplyMN. 0026.30 - NOTICE, DISQUALIFICATION OF AUTHORIZED REP. 0026.33 - NOTICE, DENYING GOOD CAUSE FOR IV-D NON-COOP, 0026.39 - NOTICE OF OVERPAYMENT AND RECOUPMENT, 0026.42 - NOTICE OF INCOMPLETE OR MISSING REPORT FORM, 0026.51 - NOTICES - CHEMICAL USE ASSESSMENT, 0027.12.03 - APPEAL HEARING EXPENSE REIMBURSEMENT, 0028.03 - COUNTY AGENCY EMPL. O t h e r P r a c t i c e N a m e : F O R M T E X T P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T A d d r e s s : F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e E - m a i l A d d r e s s : F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F e d e r a l T a x I D N u m b e r ( i f d i f f e r e n t f r o m p r i m a r y ) : F O R M T E X T C r e d e n t i a l i n g C o n t a c t : F O R M T E X T P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T C u r r e n t l y p r a c t i c i n g a t t h i s l o c a t i o n ? For policy on recertifications, see 0009 (Recertification). The date of application is the date any Minnesota county agency receives a signed and dated page number 1 of the CAF, the submittal date of an ApplyMN application or, for a person who is participant of another cash program, a signed and dated Change Report Form (DHS-2402) (PDF). m Health Care Application (HCAPP) (DHS-3417). SNAP: GRH: F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o H a s y o u r p r o f e s s i o n a l l i c e n s e o r r e g i s t r a t i o n e v e r b e e n i n v e s t i g a t e d o r i s i t c u r r e n t l y b e i n g i n v e s t i g a t e d a n d , i f s o , w h a t w e r e t h e r e s u l t s ? There are many ways to get applications for public assistance. St. Paul, MN 55101-5188. EXCEPTION: If “Did Not Sign” was typed in the signature field of an ApplyMN application or the signature on the CAF did not reasonably represent the name of someone allowed to sign the application, the application cannot be used to set the date of application. Additionally, you may download and complete the Combined Application Form (PDF). The date of application may not be the same as the beginning date of eligibility. F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o H a s y o u r D E A r e g i s t r a t i o n e v e r b e e n r e v o k e d , s u s p e n d e d , l i m i t e d , o r c o n d i t i o n e d i n a n y w a y , o r h a v e y o u v o l u n t a r i l y r e l i n q u i s h e d y o u r D E A r e g i s t r a t i o n , o r i s t h e r e a r e v i e w p e n d i n g ? Minnesota Family Investment Program (MFIP). Diversionary Work Program (DWP). Supplemental Nutrition Assistance Program (SNAP), formerly known as food support, is an electronic benefit used like money to buy food. 0026.06 - NOTICE - APPROVAL OF APPLICATION OR RECERT. ® F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o A d d r e s s : F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F r o m F O R M T E X T / F O R M T E X T / F O R M T E X T O r g a n i z a t i o n N a m e / A c t i v i t y : F O R M T E X T T o F O R M T E X T / F O R M T E X T / F O R M T E X T R e a s o n f o r L e a v i n g : F O R M T E X T E m p l o y m e n t C o n t a c t N a m e : F O R M T E X T C l i n i c S t i l l O p e n ? The benefit amount is based on income and certain expenses and the number of people in the household. ÐÏࡱá > þÿ ì î þÿÿÿ â ã ä å æ ç è é ê ë ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Á '` ø¿ èH bjbj{P{P 8¨ : : Öð ¬ ÿÿ ÿÿ ÿÿ ¤ ® A peer is defined as an individual in the same professional discipline with essentially equal qualifications (MD and DO are considered equivalent; DDS/DMD for DDS/DMD; DPM for DPM; PhD for PhD, etc.) at P.O. • The completed form should be mailed to Driver and Vehicle Services, 445 Minnesota Street, St. Paul, Minnesota 55101-5182. Unless you meet certain criteria your interview will most likely not be the same day. See 0005.12.06 (Who Must Sign Applications). ÿÿÿÿ M i n n e s o t a U n i f o r m C r e d e n t i a l i n g A p p l i c a t i o n I n i t i a l P h y s i c i a n / D e n t i s t / A l l i e d H e a l t h P r o f e s s i o n a l A p p l i c a n t N a m e : F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T L a s t F i r s t M i d d l e S u f f i x T i t l e C R E D E N T I A L I N G C O N T A C T I N F O R M A T I O N N a m e F O R M T E X T P h o n e N u m b e r ( F O R M T E X T ) F O R M T E X T - F O R M T E X T A d d r e s s F O R M T E X T F a x N u m b e r ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F O R M T E X T E - m a i l F O R M T E X T F O R M T E X T T h i s B o x t o b e c o m p l e t e d b y A l l i e d H e a l t h P r o f e s s i o n a l s O n l y P r o f e s s i o n / T i t l e F O R M T E X T S p o n s o r i n g / C o l l a b o r a t i v e P h y s i c i a n F O R M T E X T ( I f applicable) Instructions The initial credentialing application and attachments should be typed, legibly printed in black ink, or electronically generated. When MFIP is ending but the unit remains eligible for non-PA SNAP, the SNAP application date on MAXIS is the date of the MFIP closing action. F O R M T E X T F O R M T E X T 4 . Set the application date and schedule an interview. For expedited SNAP applications, follow TEMP Manual TE02.10.01 (Expedited SNAP w/ Pending Verif’s). The date of application for residents of Regional Treatment Centers (RTCs) is the date of the client's release. F O R M T E X T F O R M T E X T 3 . F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o H a s y o u r m e m b e r s h i p , p a r t i c i p a t i o n , c l i n i c a l p r i v i l e g e s , o r e m p l o y m e n t e v e r b e e n d e n i e d , t e r m i n a t e d , s t i p u l a t e d , r e s t r i c t e d , r e f u s e d , l i m i t e d , s u s p e n d e d , r e v o k e d , o r n o t r e n e w e d b y a n y p e e r r e v i e w o r g a n i z a t i o n , t h i r d p a r t y p a y e r , c l i n i c , h o s p i t a l , m e d i c a l s t a f f , o r a n y h e a l t h - r e l a t e d a g e n c y o r o r g a n i z a t i o n , o r i s t h e r e a r e v i e w p e n d i n g ? A unit is not required to reside in a permanent dwelling or have a fixed mailing address to be eligible for SNAP. Buffalo, MN 55313 Directions Ph: 763-682-7414 Fx: 763-682-8920 Hours Monday - Friday 8 a.m. - 4:30 p.m. This form is fillable so you can type in answers, print out the completed application and mail or fax it to us. Limit to one (1) current office associate. Return the application (or page 1 of the CAF depending on what you have received) to the applicant. SNAP benefits are for qualifying single people and families with or without children. R ® P l e a s e p r o v i d e c o v e r i n g p h y s i c i a n s n a m e , i f a p p l i c a b l e . O t h e r P r a c t i c e N a m e : F O R M T E X T P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T A d d r e s s : F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e E - m a i l A d d r e s s : F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F e d e r a l T a x I D N u m b e r ( i f d i f f e r e n t f r o m p r i m a r y ) : F O R M T E X T C r e d e n t i a l i n g C o n t a c t : F O R M T E X T P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T C u r r e n t l y p r a c t i c i n g a t t h i s l o c a t i o n ? Make sure you take your time and carefully fill out this application, since this can speed up the review process. F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I f y e s , s p e c i f y l a n g u a g e s : F O R M T E X T F O R M T E X T P r i m a r y o r P e n d i n g P r a c t i c e L o c a t i o n P r i m a r y P r a c t i c e L o c a t i o n / C l i n i c N a m e : F O R M T E X T A d d r e s s : F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e O f f i c e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F e d e r a l T a x I D N u m b e r : F O R M T E X T E - m a i l A d d r e s s : F O R M T E X T C u r r e n t l y p r a c t i c i n g a t t h i s l o c a t i o n ? Driver Services: 651-297-3298 Vehicle Services: 651-297-2126 Fax: 651-405-6168 Website. Email hhsews@hennepin.us; Fax to 612-288-2981; Mail to Hennepin County Human Services Dept. The date of application will be when the applicant meets the minimum requirements as listed. œ =@ P Ï= Ï= Ï= SÄ SÄ Å¬ ^ Ï= Ï= Ï= ÊÉ B B B B Ú Ú Ú äŠ ¾š Ú Ú Ú ¾š Ú Ú Ú ® Students earn a master’s degree and prepare to write the College of Nurses of Ontario’s NP – Primary Health Care (Ontario) exam concurrently.. Applications are available by contacting: 1. The premium pay-per-fax service also uses … You can also download some applications from the Minnesota Department of Human Services: Combined Appli… This PDF form is also available in Hmong, Russian, Somali, Spanish and Vietnamese. You may have someone else apply for you or help you fill out your application. We cannot respond to questions sent through this form. SERVICES/SNAP E&T, 0028.06.12 - WHO IS EXEMPT FROM SNAP WORK REGISTRATION, 0028.09 - ES OVERVIEW/SNAP E&T ORIENTATION, 0028.09.03 - CONTENT OF ES OVERVIEW/SNAP E&T ORIENTATION, 0028.09.06 - EXEMPTIONS FROM ES OVERVIEW/SNAP E&T ORIENTATION, 0028.18 - GOOD CAUSE FOR NON-COMPLIANCE--MFIP/DWP, 0028.18.01 - MFIP GOOD CAUSE--CAREGIVERS UNDER 20, 0028.21 - GOOD CAUSE NON-COMPLIANCE - SNAP/MSA/GA/GRH, 0028.30 - SANCTIONS FOR FAILURE TO COMPLY - CASH, 0028.30.03 - PRE 60-MONTH TYPE/LENGTH OF ES SANCTIONS, 0028.30.04 - POST 60-MONTH EMPL. : F O R M T E X T A d m i t t i n g P r i v i l e g e s : D e p a r t m e n t N a m e : F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o D e p a r t m e n t C h a i r p e r s o n : F O R M T E X T F O R M C H E C K B O X A p p l i c a t i o n P e n d i n g A d d r e s s F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F O R M C H E C K B O X C h e c k h e r e i f y o u h a v e a d d i t i o n a l h o s p i t a l a f f i l i a t i o n s o n a t t a c h e d H o s p i t a l A f f i l i a t i o n A d d e n d u m , p a g e 1 7 S p e c i a l t y / S u b s p e c i a l t y C e r t i f i c a t i o n C e r t i f y i n g B o a r d S p e c i a l t y / S u b s p e c i a l t y D a t e C e r t i f i e d D a t e R e c e r t i f i e d E x p i r a t i o n D a t e C e r t . Follow general provisions. If you are applying for a Sales and Use tax account for the first time, please use the interactive application found at the bottom of the page by pressing "Begin Registration". ( M o n t h , d a y a n d y e a r r e q u i r e d ) F r o m F O R M T E X T / F O R M T E X T / F O R M T E X T I n s t i t u t i o n N a m e : F O R M T E X T T o F O R M T E X T / F O R M T E X T / F O R M T E X T T y p e o f P r o g r a m / S p e c i a l t y ( t r a n s i t i o n a l , r o t a t i n g , 5 t h p a t h w a y , e t c . ) Note: If you’ve already been getting assistance from the county, you should call them and ask what you should do. : F O R M T E X T A d m i t t i n g P r i v i l e g e s : D e p a r t m e n t N a m e : F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o D e p a r t m e n t C h a i r p e r s o n : F O R M T E X T F O R M C H E C K B O X A p p l i c a t i o n P e n d i n g A d d r e s s F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F r o m F O R M T E X T / F O R M T E X T / F O R M T E X T F a c i l i t y N a m e : F O R M T E X T T o F O R M T E X T / F O R M T E X T / F O R M T E X T T y p e / c a t e g o r y o f p r i v i l e g e / a f f i l i a t i o n ( a c t i v e , c o u r t e s y , e t c . ) F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o S t a r t D a t e : F O R M T E X T / F O R M T E X T / F O R M T E X T I f y e s , w i l l y o u c o n t i n u e t o p r a c t i c e a t t h i s l o c a t i o n ? Get help applying. It may also be faxed to (651) 297-5574. F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o , p l e a s e e x p l a i n F O R M T E X T D E A N u m b e r : F O R M T E X T S t a t e : F O R M T E X T E x p i r a t i o n D a t e : F O R M T E X T / F O R M T E X T / F O R M T E X T A p p r o v e d f o r a l l s c h e d u l e s ? If your application for DEA and/or malpractice insurance are pending, please forward application and send those documents as soon as possible. Thi… Name: FORMTEXT T i t l e : F O R M T E X T F a c i l i t y N a m e : F O R M T E X T A d d r e s s : F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T E - M a i l A d d r e s s : F O R M T E X T N a m e : F O R M T E X T T i t l e : F O R M T E X T F a c i l i t y N a m e : F O R M T E X T A d d r e s s : F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T E - M a i l A d d r e s s : F O R M T E X T N a m e : F O R M T E X T T i t l e : F O R M T E X T F a c i l i t y N a m e : F O R M T E X T A d d r e s s : F O R M T E X T F O R M T E X T F O R M T E X T S t r e e t C i t y / S t a t e / C o u n t r y Z i p C o d e P h o n e N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T F a x N u m b e r : ( F O R M T E X T ) F O R M T E X T - F O R M T E X T E - M a i l A d d r e s s : F O R M T E X T L i f e S u p p o r t C e r t i f i c a t i o n D o y o u h a v e a n y c u r r e n t l i f e s u p p o r t c e r t i f i c a t i o n s ( B L S , C P R , A C L S , A T L S , e t c . )
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