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Get and Sign Lic 279  Form

Get and Sign Lic 279 Form

Use a lic 279 template to make your document workflow more streamlined.

LIST THE COUNTIES IN WHICH YOU HAVE RESIDED: CITY 4. MAILING ADDRESS (if different): 5. STATE ■ No Yes ■ No ZIP EMAIL ADDRESS (NOT REQUIRED) DIRECTION(S) TO HOME: ■ Yes ■ No DATE LICENSED/CERTIFIED: ■ Pending PHONE: CITY ADDRESS: TYPE OF LICENSE: STATE ZIP LICENSING AGENCY: LICENSE #: OTHER ADULTS IN THE HOME (Not applicant(s)) Do not list the names of persons under 18 years of age First Name 8. 9. Yes PHONE: 6. ARE YOU CURRENTLY, OR HAVE YOU EVER BEEN, LICENSED OR...
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