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Get Credit Card Payment Form - Azdhs

N the License: ADHS License # Facility I.D. # (ADHS USE ONLY) Address On The License: License Expiration Date: Applicable Licensing Office: (Check only one) Medical Facilities Behavioral Health Long Term Care Child Care This payment is for a renewal: Total Licensed or Requested Capacity: Assisted Living (validate is for a renewal only) Renewal For Child Care Facilities ONLY: Yes No Are you registered with the Empower Pack Program? RECORD OF TRANSACTION: (ADHS USE ONL.

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