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Signature Date RETURN COMPLETED FORM TO APPLICANT LICENSING AGENCY The Illinois Deaf and Hard of Hearing Commission will accept other forms of certification provided that applicable information requested on this form is contained in the certification. Please record N/A in areas which are not applicable. A. Name of Profession as it appears on license C. Date of Issuance of License E. Licensure Method Certification / Skills Assessment National Name Level State Name Level Other Endorsement of...
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