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Get CA LIC 301B 2007

_________________________ to participate in the Long-Term Care Ombudsman Program. You must enter your full name before you give this form to your reference for completion. The above named person has submitted an application to participte in the Long-Term Care Ombudsman Program. This person has selected you to write a reference statement on his/her behalf. If you are related to this person in any way, you may not complete this reference statement. Please complete the entire form. Your Name: _.

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