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Rev.01/19 Form 004 Department of Behavioral Health and Developmental Services DBHDS CRIMINAL BACKGROUND INVESTIGATION RETURNED PACKET FORM Provider Date The enclosed attachments and/or fingerprint cards are being returned for the following reason s as indicated please complete and return within fifteen 15 business days from the date of receipt. Also if checked the additional administrative fee of 13 needs to be submitted as well* Remember to include a copy of this form with your resubmission*...
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