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Control/Shelter o EMS/Rescue Squad o Pharmacy o Health Clinic o Hospice o Mid-Level Practitioner* (APRN & PA-C) * Supervising Physician: Printed Name / Signature 2. SCHEDULES: (Check all applicable) 3. ALL APPLICANTS MUST ANSWER THE FOLLOWING: (a) Are you currently licensed (if a practitioner) in South Carolina and is your license in good standing? o Yes o No SC License Number Attach a copy of.

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