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Get TX Form L 2014-2021

from every facility with which you have been affiliated in the past 5 years. Note – your licensure analyst may require additional evaluations outside the past 5 years. Applicant’s Current Full Name: ____________________Name at time of affiliation if different: _______________________ Printed Printed Applicant’s Date of Birth: ______________ Applicant TMB ID# _________________ Applicant’s Address: ____________________________Telephone: ________________ E-Mail: ____________________ Name.

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