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Get AFFIDAVIT OF SUPERVISION - STUDENT HEARING AID DEALER ... - In

Of the student s training period. 2. Give estimates of number of hours of supervised training. 3. Return form to: Professional Licensing Agency Committee of Hearing Aid Dealer Examiners 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2064 State in which affidavit executed County in which affidavit executed Date affidavit executed (month, day, year) REGISTERED HEARING AID DEALER Name of registered hearing aid dealer (first, middle, last) Hearing aid dealer.

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