Get AF 1540 2004
IRATION DATE DATE ISSUED EXPIRATION DATE SPECIALTY DATA SPECIALTY (List all specialties for which fully qualified) BOARD CERTIFICATION (Specialty Board) CERTIFICATE NUMBER FEDERAL DRUG ENFORCEMENT ADMINISTRATION (DEA)/STATE CONTROLLED SUBSTANCE REGISTRATION (CSR) FEDERAL DEA (Type) REGISTRATION NUMBER DATE ISSUED EXPIRATION DATE REGISTRATION NUMBER DATE ISSUED EXPIRATION DATE DoD Fee-Exempt Federal (Fee-Paid) STATE CSR (Name of State) VI. MEMBERSHIP IN PROFESSIONAL SOCIETIES (If ad.
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