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Get Uniform Stamp California

Acility: Yes Designated Provider - Last First MI Fax Title (MD, DO. RN, NP, etc.) Email Address Office Phone Number Other Phone Number No Title (MD, DO. RN, NP, etc.) I agree to comply with all guidelines by the State of California Department of Public Health pertaining to the use of the State Uniform Stamp. I understand that the stamp remains the property of the State of California Department of Public Health and is subject to recall at the discretion of the Department. Applicant Sig.

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