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I hold a valid College certification in Prescriptive Authority. I have completed a course in NCLS or ACLS within the past two years. Applicant s Signature Date Applied yyyy/mm/dd FOR OFFICE USE ONLY Full Registrant Rx Authority date ACLS / NCLS Evidence of Course completion Signature Date yyyy/mm/dd APPLICATION CHECKLIST In support of this application please attach the following Evidence of successful completion of a course or courses in satisfaction of the requirements for certification in...
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