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Get VA Initial Provider Application for Licensing 2017

Ermanent, black ink. The chief executive officer, director, or other member of the governing body who has the authority and responsibility for maintaining standards, policies, and procedures for the service may complete this application. 1. APPLICANT INFORMATION: Identify the person, partnership, corporation, association, or governmental agency applying to lawfully establish, conduct, and provide service: Organization Name:_________________________________________________________________________.

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