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Name of verifying official Print legibly Signature of verifying official Membership number and title Date 5. Sign the verifying official s certification statement and print your name license number or title and date. USPA OR check Make U.S. checks only payable to USPA. Signature of Applicant month year expiration date 2. NOTE USPA license exams must be administered by APPLICANT Please Type or Print USPA Membership No. Date / / 1. NOTE D LICENSE REQUIRES SIGNATURE OF S TA OR HIGHER. Mail...
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