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Get GA Verification of Employment by Applicants for Licensure by Reinstatement

And title of person verifying employment: ________________________________________________________________________________ 10. I hereby certify that I am a custodian of records at ________________________________ and the information submitted on this form is a true and correct representation of this applicant’s file with our institution. 11. Signature of employer representative completing this form: ___________________________________________Date___________________________ Employer Representat.

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