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Rest Statement Telephone: (518) 485-5378 Fax: (518) 485-5414 E-mail: CLEPCERT health.state.ny.us Web: www.wadsworth.org/labcert/clep/clep.html Part I Identifying information (Please print or type) PFI Name of Facility Address City State Zip Telephone Part II Ownership Information (Please print or type) A. List names, addresses and social security numbers for individual owners, partners, corporation officers, and/or shareholders possessing 5 percent or more of the voting shares in.

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