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Form 4/2005 Provider Name Address Authorized Person Designation Form Bureau of Criminal History Information NYS Office of Mental Health 44 Holland Avenue Albany NY 12229 Telephone No 518-549-5180 Fax No 518-549-5188 Criminal History Information Tracking System CHITS Agency Code Telephone Fax The purpose of this form is to designate the Authorized Person for your agency who is allowed to request on behalf of your agency fingerprints and criminal h.

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