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PROGRAM PRACTICES SUBMISSION FORM IMMUNIZATION PROGRAM PRACTICES Informational: (as you want it to appear publicly) Molly Howell McDowell ND.gov Email address: Program: (as you want it to appear publicly)
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Name can be anything you desire.
Anyone who wants to fill out the form.
Simply input the desired name in the appropriate field.
The purpose is to identify the specific name chosen by the individual.
Only the chosen name needs to be reported.
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