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Get MD DHR/SSA 1279 2003-2023

Ividual listed in part I). DATE: SIGNATURE: This form must sign in the presence of a Notary Public by the person named in part II. Part IV. CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL BEFORE A NOTARY PUBLIC City/County of: _______________________________________________ State of: _______________________________ Acknowledged before me this ____________________________ Day of _______________________ 20____ Notary Public My Commission expires: ______________________ Part V. BACKGROUND CLEARAN.

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