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Get NY DOH-3736 2005-2024

S NOTE: THIS APPLICATION IS FOR APPROVAL OF AGENCIES OR GROUPS OF INCORPORATED PROFESSIONALS ONLY (Use form #DOH -3735 for individual applicants). INSTRUCTIONS: See detailed instructions for DOH-3736. SCHEDULE 1 - GENERAL AGENCY INFORMATION A. Applicant Identification Agency Name Tax Identification Number /____/____/ - /____/____/____/____/____/____/____/ Agency Address (Number & Street) City County Zip Telephone ( Fax Number ( ) ) B. Name of Service Delivery Site(s) (if different f.

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