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Get Designated Agent Form - Louisiana Department Of Health And ... - Dhh Louisiana

SF13B rev. 11/10 DEPARTMENT OF HEALTH HOSPITALS OFFICE OF PUBLIC HEALTH Designated Agent Form AFFIDAVIT STATE OF LOUISIANA PARISH OF BEFORE ME on this day of the undersigned notary public commissioned in and qualified for the Parish and State aforesaid and the two undersigned competent witnesses personally came and appeared Property Owner Print do hereby appoint as my designated agent for the purposes of securing a temporary permit to install an.

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