ADHS Licensing Survey

 
This survey is designed to determine licensing needs among our providers.
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1. Facility Name
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2. E-mail address
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3. License Number
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4. Your name (first and last):
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5. Position/Title:
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6. License Expiration Date
MM DD YYYY
01/01/2013-12/12/2015
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7. Which bureau or office licenses your facility?
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8. What type of facility are you CURRENTLY licensed as: