Get Amalgam Separator Installation Self-certification Form General ... - Des Nh

This guide provides clear, step-by-step instructions on how to accurately complete the Amalgam Separator Installation Self-Certification Form. By following these directions, users can ensure their submissions are complete and compliant.

Follow the steps to complete your self-certification form effectively.

1. Click the ‘Get Form’ button to access the form and open it in your chosen document editor.
2. In the 'General Information' section, provide the name of your practice, street address, and owner's name(s). Include a phone number and mailing address, along with your city/town and zip code. Finally, input a valid e-mail address.
3. Proceed to the 'Amalgam Separator Information' section. Fill in the manufacturer name, model, and maximum flow rate of the amalgam separator. Indicate the installation date and the number of chairs the separator serves.
4. For the written description of the amalgam separator's location, provide clear details. If preferred, attach a sketch that illustrates the location. Use detailed language to convey the position of the separator within your practice.
5. Move to the 'Signature' section. Sign and date the form, and ensure an authorized individual's signature is included.
6. Once all fields are filled and checked for accuracy, save your changes. You can also download, print, or share the form as needed.

Complete your documents online with confidence and submit them as required.