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Get Dona Application/Affidavit for Birth Doula Recertification Active Status

US Please print legibly and complete the form in its entirety First and Middle Name: Full Name for Web site: Mailing Address: City: Zip/Postal Code: Referral Phone Number: Referral E-mail Address: Orig. Cert. Date: Last Name: State/Province: Country:  Cell Cert. ID No.:  Home Cert. Expir. Date:  I am changing from Inactive to Active status (Fee: $25.00US enclosed or Order Confirmation #__________)  I purchased a six (6) month extension for this recertification period (copy of re.

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