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Complete Subsection 2 only if the owner is a sole proprietorship. Subsection 2 For the purposes of Neb. Division of Public Health - Licensure Unit PO Box 94986 Lincoln Nebraska 68509 Telephone 402-471-0153 Fax 402 742-1152 Attn Jacye Email jacye. 02A 12-004. 04A 12-004. 04B 12-004. 05C 12-004. 07 item 7 and 12-004. 08. SIGNATURE OF PHYSICIAN MEDICAL DIRECTOR Attestation This section is to be completed by the owner s /applicant s. NOTE You may still be eligible for a license if you provide a...
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