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Get CA SDSC ADM-219A 2011-2024

M RESOURCE LISTS (PRL) PROVIDER AFFIDAVIT Program Name: Legal Name of Organization: Street Address: City, State, Zip Code: Phone and Fax # s: Email Address: Website address: (If available. To be used as a customer point of contact.) Contact Person s Name: Name of Requested List: See Policy for Instructions and Available Lists I hereby acknowledge the following: This program/organization and staff are insured in compliance with all legal requirements. This program/organization and st.

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