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Get Disclosure Of Ownership Form Texas Clia

Address (number, street) City CLIA number Taxpayer ID number (EIN) State ZIP code Telephone number ( ) II. Answer the following questions by checking Yes or No. If any of the questions are answered Yes, list names and addresses of individuals or corporations under Remarks on page 2. Identify each item number to be continued. YES NO A. Are there any individuals or organizations having a direct or indirect ownership or control interest of five percent or mor.

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