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PERSONAL CARE SERVICES PROGRAM PROVIDER CERTIFICATION APPLICATION Part 1. Demographic Information Check one: New Applicant Continuing Certification ___ Legal Name of Agency___ DBA (Doing Business

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Individuals who require personal care services and meet the eligibility criteria

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Seniors who are in need of personal care services are required to file for the program.

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Seniors must report their personal care needs and any other relevant information required by the program.

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