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[DOC File]Exhibit 5-3: Acceptable Forms of Verification
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Copies of cancelled checks that verify payments on outstanding medical bills that will continue for all or part of the next 12 months. Copies of income tax forms (Schedule A, IRS Form 1040) that itemize medical expenses, when the expenses are not …
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[DOC File]PENNSYLVANIA DEPARTMENT OF HEALTH
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Pennsylvania License (Physician / PHRN) Attachments for Questions 1-4 (if applicable) I hereby certify that the information provided in this application is true and correct to the best of my knowledge, information, and belief. I grant the ALS service / medical director permission to investigate all information on this application, and grant ...
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[DOC File]IN THE COURT OF COMMON PLEAS OF ALLEGHENY …
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA. FAMILY DIVISION/ADULT SECTION. PACSES CASE ID Petitioner ... I believe that I am entitled to maintain my driver’s license because: I verify that the statements made in the Petition are true and correct. I understand that false statements herein are made subject to the penalties ...
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[DOT File]IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, …
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Pursuant to 75 Pa.C.S.A. § 1550(b)(1)(i), Appellant is retaining driver’s license until final determination of the suspension of operating privilege. Pursuant to 75 Pa.C.S.A. § 1550(b)(1)(ii), a hearing attended by the Appellant must be held before the Court of Common Pleas before an order of supersedeas can be issued.
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[DOCX File]DOH - Pennsylvania Department of Health
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I also certify that the acute care hospital named in this Application has provided information to verify that it holds a valid hospital license with the Department of Health. A false statement made in this Application is punishable under the applicable provisions of 18 Pa. C.S. Ch. 49 (relating to falsification and intimidation).
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[DOCX File]COMMONWEALTH OF PENNSYLVANIA
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Commonwealth of Pennsylvania. Insurance Department. LICENSE NUMBER: BUSINESS EMAIL: INSURANCE ADMINISTRATOR License . Renewal addendum. INSTRUCTIONS. To renew your . I. nsurance . A. dministrator’s license: 1)Verify the name and license number on the License Renewal Notice.
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[DOCX File]FEDERAL TAX ID (EIN) NUMBER
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Verify the name and license number on the License Renewal Notice. Provide a copy of any new fictitious name filing from the Pennsylvania Department of State. Attach a completed Biographical Affidavit for each officer, director and office manager that has not …
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[DOC File]PFBC-715 (08/02) - Pennsylvania Fish & Boat Commission
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PFBC-L-114 (11/18) ALL INFORMATION SHOULD BE TYPEWRITTEN OR PRINTED PLAINLY IN INK. Applicant: I/We hereby make application for a Fish License Issuing Agency for the Commonwealth Of Pennsylvania, Pennsylvania Fish and Boat Commission, in accordance with Act 1980-175 known as the Fish and Boat Code, Title 30 PA. C.S. as amended, to issue …
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[DOC File]MEDICAL COMMAND AUTHORIZATION APPLICATION
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( Pennsylvania License (Physician/PHRN) ( Attachments For Questions 1-4 (If Applicable) I hereby certify that the information provided in this application is true and correct to the best of my knowledge, information, and belief. I grant the ALS service/ medical director permission to investigate all information on this application, and I grant ...
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[DOC File]SP 4-127 (2-20003)
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by signing this application, i acknowledge that if a license is granted, i give permission to the pennsylvania state police, or their designee, and the issuing authority to come to the business location and inspect the premises, records, and documents without warrant, to ensure compliance with 37 pa. code § 33.1 et seq.
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Verify pennsylvania license