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Get NY DOH-4330 2012

Be â–¡ Describe Additional Security SUPERVISOR OF CONTROLLED SUBSTANCE ACTIVITY (complete only if an individual other than the applicant will be supervising controlled substance activity) Name Title Signature Type of Professional License and Number APPLICANT ACKNOWLEDGEMENTS The applicant fully understands that the license to be issued hereon shall be subject to the following stipulations and conditions: 1. The applicant is knowledgeable concerning all laws and regulations, both State a.

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