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PRINTED: 06/20/2012 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION A.
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Anyone who is applying for a state professional license or certification needs to fill out the state licensure survey form. This form is typically required by state licensing boards or regulatory authorities to assess an individual's qualifications and eligibility for obtaining or renewing a professional license. It is necessary for various professions such as doctors, nurses, teachers, engineers, lawyers, and many others.
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Form state licensure survey is a document used to gather information about licensure status in a specific state.
All individuals or entities holding a license in that particular state are required to file form state licensure survey.
Form state licensure survey can be filled out online or submitted through mail with the required information about licensure status.
The purpose of form state licensure survey is to ensure that all license holders are in compliance with state regulations.
Information such as license number, expiration date, renewal status, and any disciplinary actions must be reported on form state licensure survey.
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