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?????,O, 9 <br />I hereby affirm ttiat the information submitted in this applicarion is true to the best of my knowledge and belief and is fiunished in good faith. I <br />understand that significant omissions or misrepresentarions may result in denial of application or termination of privil aes, employment or participating <br />practitioner agreement. <br />A photocopy 's doc p a <br />ll be <br />as e as the original. <br />Preparer's Name Here <br />Sia ature <br />(Stamped Sio ature Is Not Acceptable) <br />? <br />? <br />Titie <br />09 <br />Date <br />Facility Application -10/03; revised 12/05, 7/06, 9/06 Page 3of 3