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Get CA LIC 508 2015-2024

Rue and correct to the best of my knowledge. Signature ____________________________________________ Date ____________________ II. Instructions to Licensees: If the person discloses a criminal conviction, review the person’s statement and discuss it with your Licensing Program Analyst (LPA). Maintain this form in your facility/organization personnel file and send a copy to your LPA. PRIVACY STATEMENT Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (C.

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