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Get CA HHSA DSS LIC 9215 2012

_______ Certificate Number: ___________________ Issuing Government Agency: _______________________________________________ 3. Are you currently or were you previously employed by a licensed community care facility? If yes, please indicate the facility name(s) and license number(s); I Yes I No Facility Name: __________________ License Number: ______________________ Facility Name: __________________ License Number: ______________________ Facility Name: __________________ License Number: .

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