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Date: Company Name: Attention: Address: City:State: Zip: Telephone:Fax: *****LICENSE VERIFICATION***** Fill in the italicized blanks only. Practitioner Name: License Number: ******************************************************************************************
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It is a form where information must be entered in italicized text.
Individuals and businesses who meet certain criteria.
By following the instructions provided on the form and entering the required information in italicized text.
To collect specific information from individuals and businesses.
Certain financial and personal information.
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