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Children and Adult Licensing SECTION I FACILITY INFORMATION 1. Type of Application: INITIAL MODIFICATION: Specify Change Effective Date of Change 2. Certificate Type (Population served must be mentally ill and/or developmentally disable as authorized by AFC License.) MENTAL ILLNESS DEVELOPMENTAL DISABILITY MENTAL ILLNESS & DEVELOPMENTAL DISABILITY 3. Facility Name 4. Facility Street Address 5. Facility City, State, Zip 6. Area Code/Telephone Number 7. Area Code/Fax Number 8. Email.

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