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Get Ehs 769 Form

3-3108 or (518) 233-3109 Fax - (518) 233-3132 PERSON REQUESTING EXAMINATION Date of Request: Print Name: Title: Phone Number: Fax Number: Agency Name and Address: Agency Code: Cost Center Code: Division: Preferred Service Location (See Note #1 below) I affirm that the candidate referenced below has been given a conditional offer of employment. Signature of Person Requesting Examination: Name of Agency Payment Coordinato.

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