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CLINICAL MENTAL HEALTH COUNSELING (MHC) PROGRAM
PRACTICUM AFFILIATION AGREEMENT
Students Name Agency address
CityStateZipPhoneStateZipPhone1Agency Representative Name :
Supervisor name/license
Supervisor
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What is agency representative name?
Agency representative name refers to the individual authorized to represent an agency in official matters.
Who is required to file agency representative name?
The head of the agency or a designated official is typically required to file the agency representative name.
How to fill out agency representative name?
The agency representative name can be filled out on a designated form provided by the relevant governing body.
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The purpose of agency representative name is to establish a point of contact for official communications and decision-making.
What information must be reported on agency representative name?
The required information typically includes the name, position, and contact details of the agency representative.
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