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Get Va 10-2850c 1998

AGAINST YOUR CERTIFICATION OR REGISTRATION (If " YES" explain on separate sheet) NO YES 17C. HAVE ANY OF YOUR STAFF APPOINTMENTS OR CLINICAL PRIVILEGES EVER BEEN DENIED, REVOKED, SUSPENDED, REDUCED, LIMITED, OR VOLUNTARILY RELINQUISHED (If " YES" explain NO YES on separate sheet) III - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE CERTIFICATION: I certify that I have verified licensure and registration with State boards, and sighted visa or evidence of citizenship. Board certi.

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