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This form will need specific info to be filled in, therefore ensure you take whatever time to type in what is asked:
1. The Learners will require particular details to be entered. Make sure the following blanks are complete:
2. After filling out this section, head on to the next stage and fill out all required particulars in all these fields - PROVIDERS STREET ADDRESS, CITY, STATE, ZIP, I am a licensed, Physician, TherapistCounselor, Social Worker, My practice includes assisting, opinion the applicants gender, Female, and can reasonably be expected to, I hereby certify under penalty of, PROVIDERS SIGNATURE WARNING, and DATE.
3. This 3rd part should also be fairly straightforward, I wish to contribute to the, FEE PAID, In This Amount, SEE REVERSE FOR FEES, XSIGN, HERE, WARNING Misstatement of fact is a, and APPLICANTS SIGNATURE IN INK DATE - all of these empty fields has to be filled out here.
Be extremely mindful while completing APPLICANTS SIGNATURE IN INK DATE and HERE, as this is the section where many people make some mistakes.
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