ࡱ> %("#$_ D.bjbj 8<bb2=2 2 8,l(T d†ĆĆĆĆĆĆ$E$$$4-F,,,$R†,$†,,gszUMĦ %Tx<sHx4%xzz{ | ~!,6""| | | (H| | | $$$$| | | | | | | | | 2 R: State of Florida Department of Business and Professional Regulation Division of Drugs, Devices, and Cosmetics Application for Permit as a Health Care Clinic Establishment Form No.: DBPR-DDC-224 APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. APPLICATIONAPPLICATION REQUIREMENTSApplication for Permit as a Health Care Clinic Establishment  FORMCHECKBOX  Submit a biennial application fee of $255.00, made payable by cashier s check, corporate or business check, or money order, to the Florida Department of Business and Professional Regulation.  FORMCHECKBOX  If you answer  Yes to any question in Section IV, be sure to provide a detailed explanation along with any relevant documentation.  FORMCHECKBOX  Sign and date the Affidavit section of the application. Submit the completed application with enclosures to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399  PLEASE NOTE: Telephone, email, and fax contact information is used to quickly resolve questions with applications. If such information is not provided, questions regarding applications will be mailed to the application contacts mailing address and may take longer to resolve. State of Florida Department of Business and Professional Regulation Division of Drugs, Devices, and Cosmetics Application for Permit as a Health Care Clinic Establishment Form No.: DBPR-DDC-224 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Division of Drugs, Devices and Cosmetics, at 850.717.1800. For additional information see the instructions at the beginning of this application. Section I Application Type CHECK ONE OF THE APPLICATION TYPES FORMCHECKBOX  New Application [3360/1020]  FORMCHECKBOX  New Application due to Change in Ownership. If checked, provide legal documentation for the change of ownership (i.e. Bill of Sale, stock transfer, merger). [3360/1020] Current Permit Number: ___________________________  Section II Applicant Information APPLICANT INFORMATIONTAXPAYER IDENTIFICATION NUMBER OR FEDERAL EMPLOYER IDENTIFICATION NUMBER This is a unique nine-digit number assigned by the Internal Revenue Service (IRS) to business entities operating in the United States for the purposes of identification. When the number is used for identification rather than employment tax reporting, it is usually referred to as a Taxpayer Identification Number (TIN), and when used for the purposes of reporting employment taxes, it is usually referred to as the Federal Employer Identification Number (FEIN).Applicants TIN/FEIN: FULL LEGAL NAME The full legal name is the complete name of the business entity that will be operating the establishment. This is generally the name that is on the documents that establish the existence or formation of the business entity. For example, a corporations full legal name would normally be the name that is found in the corporations articles of incorporation.Applicants Full Legal Name: FICTITIOUS, TRADE, OR BUSINESS NAME If the applicant intends to operate the permitted establishment under a name that is different from the Applicants Full Legal Name listed above e.g. fictitious, trade, or business name (also commonly referred to as a dba, D/B/A, or doing business as name this name must be registered with the Florida Department of State, Division of Corporations. This is the name that will appear on the permit issued to the applicant by the department and must be the name that the applicant uses on operational documents for permitted activities.   FORMCHECKBOX  The applicant WILL NOT operate the permitted establishment under a name that is different from the Applicants Full Legal Name listed above.  FORMCHECKBOX  The applicant WILL operate the permitted establishment under the following fictitious, trade, or business name: ___________________________________________________________________ The fictitious, trade, or business name listed directly above, is registered with the Florida Department of State, Division of Corporations and the applicant has been issued the following registration number: ______________________________. APPLICANTS MAILING ADDRESSStreet Address or P.O. Box:City:State:Zip Code (+4 optional):PHYSICAL ADDRESS OF ESTABLISHMENT TO BE PERMITTED (only if different from mailing address) Check  FORMCHECKBOX  if not applicableStreet Address: City: State:Zip Code (+4 optional):County (if Florida address):Country:E-Mail Address:Phone Number:Fax Number: APPLICATION CONTACTThe application contact is the person that the department will contact if there are questions regarding the responses provided on, or the documentation submitted with, the application. The application contact is also the person that will receive all official communication from the department regarding the application.Last/Surname: First: Middle: Suffix:Address:City:State:Zip Code (+4 optional):Telephone Number:Fax Number:E-Mail Address: DESIGNATED QUALIFYING PRACTITIONERThe designated qualifying practitioner is the person that the department will contact regarding legal and or regulatory issues related to the purchase, recordkeeping, storage, and handling of prescription drugs. The department will contact this person at times outside of the regular business hours listed below. The contact information provided should be sufficient for the department to actually reach and communicate with the designated qualifying practitioner.Last/Surname: First: Middle: Suffix: Street Address:City:State:Zip Code (+4 optional):Telephone Number:E-Mail Address:License # With Prefix: Expiration Date: ___ / _____ / _______ Issuing regulatory board (e.g.: Florida Board of Medicine): Is qualified practitioner authorized under the appropriate practice act to prescribe and administer prescription drugs? If no, please explain. Explanation Attached?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A FORMCHECKBOX  Yes  FORMCHECKBOX  NoQualifying Practitioner Affidavit: I UNDERSTAND that as the qualifying practitioner I will be responsible for complying with all legal and regulatory requirements related to the purchase, recordkeeping, storage, and handling of the prescription drugs. I UNDERSTAND that my name, the establishment address, and my license number will be used on all distribution documents for prescription drugs purchased or returned by the health care clinic establishment. I UNDERSTAND that a violation of Chapter 499, Florida Statutes, by the health care clinic establishment or me as the qualifying practitioner constitutes grounds for discipline of my health care practitioner license by the appropriate regulatory board.Signature of Designated Qualifying Practitioner: Date:  OPERATING HOURSList the establishments daily hours of operation in terms of Eastern Time. REMEMBER to circle a.m. or p.m. for each time indicated below.Mon : a.m./p.m. to : a.m./p.m. Tue : a.m./p.m. to : a.m./p.m. Wed : a.m./p.m. to : a.m./p.m. Thu : a.m./p.m. to : a.m./p.m. Fri : a.m./p.m. to : a.m./p.m. Sat : a.m./p.m. to : a.m./p.m. Sun : a.m./p.m. to : a.m./p.m. Section III Ownership Information TYPE OF OWNERSHIP  FORMCHECKBOX  Publicly Held Corporation  FORMCHECKBOX  Closely Held Corporation  FORMCHECKBOX  Limited Liability Company  FORMCHECKBOX  Charitable Organization501(c)(3) FORMCHECKBOX  Sole Proprietorship FORMCHECKBOX  Government FORMCHECKBOX  Partnership General  FORMCHECKBOX  Professional Corporation or Association FORMCHECKBOX  Professional Limited Liability Company  FORMCHECKBOX  Partnership Other, Including Limited Liability Partnership and Limited Partnership  FORMCHECKBOX  Other:__________________List the state of incorporation or state of organization (except Partnership General or Sole Proprietorship). Business entities organized under non-U.S. laws list the country of organization.  FORMCHECKBOX  N/A (Partnership General or Sole Proprietorship)State or Country: List name and address of the applicants registered agent for service of process in Florida (except Sole Proprietorship or Partnership General) and provide documentation, such as a print out from the Florida Department of State, Division of Corporations webpage, that the applicants registered agent is registered with the Florida Department of State, Division of Corporations.  FORMCHECKBOX  N/A (Partnership General or Sole Proprietorship)Name: Address: City:State:Zip Code (+4 optional):List the name, position/title, social security number, date of birth and address of each owner, partner, member, manager, officer, director, chief executive, or other person who directly or indirectly controls the operation of the business entity, as applicable. For example, corporations would list officers and directors, limited liability companies would list members and managers, etc.1.Name & Title: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code:2.Name & Title: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code:3.Name & Title: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code:4.Name & Title: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code:5.Name & Title: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code:List the name, social security number, date of birth and address of each person who owns 10 percent or more of the outstanding stock or equity interest in the business entity.1.Name: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code: 2.Name: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code: 3.Name: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code:4.Name: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code:5.Name: Social Security #:Date of Birth:% of Ownership:Street Address: City:State:Zip Code:List all trade or business names used by the applicant. Use additional sheet(s) if necessary. If the applicant does not use other trade or business names check this box  FORMCHECKBOX  and write N/A on the lines below.  Section IV Background Questions BACKGROUND QUESTIONS1. FORMCHECKBOX  Yes If yes, explain in detail in Section V FORMCHECKBOX  NoHas the applicant or designated qualifying practitioner been fined or disciplined by a regulatory agency in any state (Including Florida) for any offense that would constitute a violation of Chapters 456, 465, 474, 499, or 893, F.S., related to the distribution, possession, administration, or dispensing of prescription drugs?2. FORMCHECKBOX  Yes If yes, explain in detail in Section V FORMCHECKBOX  No Has the applicant or designated qualifying practitioner ever entered a plea to, been convicted or found guilty of, any felony under a federal, state (including Florida), or local law related to the distribution, possession, administration or dispensing of prescription drugs? Include all cases where a guilty, nolo contendere or no contest plea was entered, whether or not adjudication was withheld.3.  FORMCHECKBOX Yes If yes, explain in detail in Section V FORMCHECKBOX  NoHas the applicant or designated qualifying practitioner had any current or previous permit or license suspended or revoked which was issued by a federal, state, or local government agency relating to the manufacturing, distributing, prescribing, dispensing, or administration of prescription drugs?4.  FORMCHECKBOX  Yes If yes, explain in detail in Section V FORMCHECKBOX  NoHas the applicant or designated qualifying practitioner been denied a permit or license in any state (including Florida) related to an activity regulated under Chapters 465, 499, or 893, F.S.? If you answered YES to any questions in Section IV, you must provide detailed explanations in Section V, including requirements for submitting supporting legal documents. If needed, explain on separate sheet(s). Section V Explanation(s) for Yes response(s) to background question(s) in Section IV EXPLANATION(S) Section VI Other Permits or Licenses PERMITS OR LICENSES1.Are there any other permits or licenses issued by any agency of the State of Florida that authorize the purchase or possession of prescription drugs at the applicants establishment or address? (If no, please check this box  FORMCHECKBOX  and write N/A in the lines below). FORMCHECKBOX  Yes  FORMCHECKBOX  No1a.Permit/License NamePermit/License TypePermit/License Number Section VII Affidavit AFFIDAVITPursuant to s. 559.79, F.S., each application for a license or renewal of a license issued by the Department of Business and Professional Regulation shall be signed under oath or affirmation by the applicant, or owner or chief executive of the applicant without the need for witnesses unless otherwise required by law. Pursuant to s. 559.791, F.S., any license issued by the Department of Business and Professional Regulation which is issued or renewed in response to an application upon which the person signing under oath or affirmation has falsely sworn to a material statement, including, but not limited to, the names and addresses of the owners or managers of the licensee or applicant, shall be subject to denial of the application or suspension or revocation of the license, and the person falsely swearing shall be subject to any other penalties provided by law. I UNDERSTAND THAT THE ISSUANCE OF A PERMIT BY THE DEPARTMENT ONLY AUTHORIZES THE APPLICANT TO CONDUCT REGULATED ACTIVITIES IN THE STATE OF FLORIDA UNDER THE NAME IN WHICH THE PERMIT IS ISSUED. IF THE PERMIT IS ISSUED IN THE NAME OF A DBA OR D/B/A THE APPLICANT MAY ONLY CONDUCT BUSINESS IN FLORIDA IN THE NAME OF THE DBA OR D/B/A. I FURTHER UNDERSTAND THAT PROVIDING ADDITIONAL DBA OR D/B/A NAMES TO THE DEPARTMENT AS PART OF THE APPLICATION PROCESS IS NOT, UPON LICENSURE, AN AUTHORIZATION TO CONDUCT BUSINESS IN FLORIDA UNDER THE NAME OF THOSE ADDITIONAL DBAS OR D/B/AS. I certify that I am empowered to execute this application as required by s. 559.79, F.S. I understand that my signature on this application has the same legal effect as if made under oath. To the best of my knowledge, all information contained on this application is true and correct. I CDPmno{~C E G R S m } ¹~wpwib hhj75\ hPY5\ h s35\ hA,5\hm=h)[5\ h)[5\h~5CJaJhES{h)[5CJaJhD h)[5CJaJhr5CJaJhe=5CJaJh5Qh}<5 hk>5 hhj75 h<5 h5 h}<5 h s35 hPY5 hd5 h$5h5Qh$5#DnoE G S l $$$Ifgd'$$gd~$$gdr $ $a$gd}< $ $a$gd s3 $ $a$gd$ l m h\K:K$If^`Kgd; $If^;` gd, $$$Ifgdp tkd$$IfTl    .0}$   0    h%64 lapyt T   > F N T V Z ^ ~ D ÿߓ÷s÷oh9>&j *hvhOJQJUh64(hKhL`&j` *hvhOJQJUhA,h<hsOhhj7hPYh]h!t{h 5OJQJ&j *hvhOJQJU *hvOJQJj *hvOJQJU *h}<OJQJ* D F H G|kdL$$IfTl     0}$0    h%64 laytKT $IfgdPY; $If^;` gd,K$If^`Kgd$If^`gd 5D F H J ` OPQRz 6fghiop!'0345ENȽȸxtphCh! hAhXhahXCJaJh5QhX5 hhj75 h<5 h 5 hC5 h!5 hd5h5QhX5 hX5h rhW56\ h"5 hVh<h< he=he=hhlhPYh5 he=5\ h)[5\ hXh)[,H J 2OPQRYQ$a$gd)[|kd$$IfTl     0}$0    h%64 layte=T H$If^HgdPYH[$If^H`[gd9 $$$Ifgdp tR_ghijklmno45[]zgd-   gd~d$a$gdC `gdX $ $a$gdXgdW $ $a$gdX$a$gd<$%()EFZ[\]fhtuzǿǜxq[*jha-hCCJUfHq h5Qh- h5Qh- 5h- h- 5 hZl5 h- 5 hX5 h~d5hahX56>*hls56>*hPb}56>*h$56>*hs56>*hE4hX56>*h"56>* hC5 h!5 hYo5hAhX5hd hAhXh!z~pZH6 !h$If^hgd-  !h$If^hgd6. !h$If^h`gdC  !$IfgdCukd$$IfTl    $h%   0    4 lap yt(T $$Ifa$gdw[RV~տ||vmd]XPXh9WChX5 h- 5 h5Qh- h]h- CJhWSh6.CJ h:dCJ hXCJ hCJ hVDCJ0jha-hRkCJUfHq h- CJ hhj7CJ h6.CJ hCCJ*jha-hCCJUfHq 0jKha-hRkCJUfHq !ha-hCCJfHq |th $$Ifa$gd,$a$gd   gd~dzkd3$$IfTl4    $h%  0    4 laf4p ytCTIJKOo&0123B Ŀijwwpk_h\hqS5CJaJ hZl5 h@hqSh~hqS5hqS h*QhqS h^hqSh^hqSB*mH phsH h^hqSmH sH hqSmH sH h^hqS5CJaJ hqS5h^hqS5 h5Qh hES{h 5 hWm 5h h 5h5Qh 5 h~h:G^h9WChX5"JK02I@@ $Ifgd Pkdt$$IfTl$h%   h%4 lap yt(T $$Ifa$gd $$Ifa$gd Nkd$$IfTl$h%     h%4 lap yt(T23CVMM $Ifgd Pkd$$IfTl$h%   h%4 lap yt T $$Ifa$gd $$Ifa$gd @kd $$IfTl$h%  h%4 layta-TVI h$If^hgdqSPkd$$IfTl$h%   h%4 lap yt(T $$Ifa$gd $$Ifa$gd@kd$$IfTl$h%  h%4 layta-T ()**+TUuvw4:ދބބ|wohEhZl5 hZl5h~hZl5 h@hqS hqS5hZlhqSCJ aJ h^hqSCJ aJ hZlj hqSUh^hqSCJaJj. hqSUjhqSUhqShqSCJaJ h*QhqSh~hqS5h\hqS5hqS h\hqS'>TUuvwu $$Ifa$gd,@kd $$IfTl$h%  h%4 layta-T $Ifgd h$If^hgdqS $IfgdqS $If^gdqSh$If^h`gdf)F g@kd# $$IfTl$h%  h%4 laytx$T $Ifgd,Nkd $$IfTl$h%   h%4 lap yt(T ^NBB $$Ifa$gdZlfkd $$IfTlFl$ T  h%    4 layta-T $Ifgd,@kd $$IfTl$h%  h%4 laytx$T:;IJK]^_nopqvw@NOXYbcmnwx~K̴̹̭̭hb h@hqS hqS5hR}-hqS5hqS h@hqS h*QhqSh~hqS5j hEhZl5UhEhZl5jhEhZl5UB^_opqwxg@kd $$IfTl$h%  h%4 laytT $IfgdNkdV $$IfTl$h%   h%4 lap yt(T;Skd0$$IfTl0x$  h%4 laytI;T $Ifgdfkdc$$IfTlFl$ T  h%    4 laytVTD8 $$Ifa$gd,fkd$$IfTlFx$ * Z  h%    4 layta-T $IfgdJ$Eƀ0B 'IfgdABoSJ $IfgdPkd*$$IfTlL$h%   h%4 lap yta-T $$Ifa$gd<Pkd$$IfTl1$h%   h%4 lap yt(TopyzM@kdD$$IfTl$h%  h%4 laytT $Ifgdgkd$$IfTl    $h%0    h%4 laytT;2 $Ifgd,Skd$$IfTl0$  h%4 layt#jT $Ifgdfkd$$IfTlF$ 6  h%    4 laytT _S $$Ifa$gd<Pkd$$IfTlC$h%   h%4 lap yt(T $$Ifa$gd<Ckd$$IfTl4$h%  h%4 laf4yt `T !! !!!!,!-!/!8!?!@!O!P!R!!!!!!!a"w"x"y""""""""""""""""""""""ڼڵڪڵڵjhqSUjhZlU h*QhZljnhZlUjhZlUjhZlUhZl hZl0J hqS0Jh: h*QhqShqS h@hqS; !>5 $Ifgd<gkd$$IfTl    $h%0    h%4 laytT $IfgdPkd6$$IfTlC$h%   h%4 lap yta-T! !!!.!/!A!Q!Nfkd$$IfTlF$ 6  h%    4 laytx$T $Ifgd,@kdP$$IfTl$h%  h%4 layt<TQ!R!i!j!{!|!!!!! $Ifgd,Skd$$IfTl"0$ h h%4 laytLiT !!a"b"""ul $Ifgd#j $$Ifa$gdZl $IfgdZl$Ifgd#jofkd+$$IfTl8F$6  h h%    4 laytLiT"""""""""""# # # # %"%%%%%%%%%%%&&&&&&&&&&&ɏք}vk_k_k_khEhZl>*CJaJhEhZlCJaJ h]h] hR}-hqSh*QhqSB*ph h<hqS)h<hqSB*CJOJQJ^JaJphhhZlB*phhhqSB*phhhqS5 hqS5hJYVhqS5 h*QhqSjhqSUhqSjhqSUjZhqSU%"" # ###$$%||||| $$Ifa$gd $Ifgd,nkdF$$IfTl*0<$  h%4 lapyt<T%%%%%%%%%%%%aSkd$$IfTl0<$  h%4 layt<T $Ifgd `@kd$$IfTl$h%  h%4 layt<T %&&&v $Ifgd5wkd$$IfTl    ^$h%  0    h%4 lap yt(T $IfgdNm&&&'c'''4(x(}} $IfgdF xx$IfgdFgkd$$IfTl    -$h%0    h%4 layt#OGT&&&&&&&&&&&&&&&&' ' ''''''''''"'+','5'7'8'9':'<'='>'?'E'N'O'X'Z'['\']'_'`'a'b'h'q'r'{'}'~''''''''''''''''''''''''''''''hZlCJaJ h*QhZlhEhZlCJaJhEhZl>*CJaJV''''''''''''''''''( ( ( ( ((((((( ()(+(,(-(.(0(1(2(3(8(A(B(K(M(N(O(P(R(S(T(U(Z(c(d(m(o(p(q(r(t(u(v(w(y(z({(((((ǿh9WCh*Q5 h*Q5h*Qhj 5h*Qh 5 h*Qhh#OG h*QhZlhEhZl>*CJaJhZlCJaJhEhZlCJaJEx(y(z({(((v $Ifgd,gd zkd]$$IfTl    0H$  0    h%4 laytI;T(((((((((((((((((((((( ) ) ))))))9):);)<)J)K)L)M)n)o)p)~)))))~sj)"hRkUhL`j!hRkU h*QhR}-j hRkUj hRkU h*QhdhhdhjhRkUhVjhVUhR}- h*QhGSh*Qh B*ph h*Qh h*Qh&!5h5Qh*Q5 h~h*Q-((((( ) )9):) $Ifgd>ukd$$IfTl    $h%   0    h%4 lap yt(T:);)o))) $Ifgd>fkd!$$IfTlFP$|  @     h%    4 laytL`T)))))))))))))))))))))))****'*(*)***?*A*S*T*U*V*d*e*f**********޹ުޣϐυ~ h*QhZlj&hoo+Uj%hoo+Ujhoo+U h*Qhoo+hL,j$hRkUhL`j$hRkU h*QhR}-hoo+j#hRkUhdhj"hRkUhVjhVU h*Qhdh0))))*S*T* $Ifgd> $Ifgd9fkd#$$IfTlFP$| @   h%    4 laytL`TT*U***** $Ifgd> $Ifgdoo+fkd%$$IfTlFP$| @   h%    4 laytL`T**++ $$Ifa$gdZl $IfgdZlfkd&$$IfTlFP$| @   h%    4 layta-T****++++#+++++++++,,,, ,------------------....'.?.Q./~y~y hqS5h*QhqS5h h*Qh#OG h#OGh#OG h#OGh7 h#OGh h#OGh}< h*Qhj(hZlU h^hZl h*Qh$ h<h$ h<h}< h*Qh j('hZlUjhZlU h*QhZlhZl/++, $Ifgdwkd'$$IfTl    $h%  0    h%4 lap yt(T,, , ,-- $IfgdZlnkdM($$IfTl    $h%0    h%4 lap yta-T---- $Ifgdwkd`)$$IfTl    $h%  0    h%4 lap yt(T---- $Ifgd $Ifgd#OGgkd*$$IfTl    $h%0    h%4 layt)T----. $Ifgdgkd*$$IfTl    $h%0    h%4 layt)T../qe $$Ifa$gdkd/+$$IfTl    Fr $0    h%    4 layta-T//////////////////////0000&040507080D0E0G0H0Y0Z0_0`0f0g0p0r0u000000000000000000000011111&1'1)1*1;1<1A1B1H1I1R1T1W1f1g1y11 h*QhZlhZlh^hZlCJaJ h*Qh h*Qh 5V///////// $IfgdFukd+$$IfTl    $h%  0    h%4 lap yt(T///////JA88AA $IfgdF $Ifgd kd,$$IfTl4    r<$`z0    h%4 laytZlT//00000A888 $IfgdFkdV-$$IfTl4    r<$ z0    h%4 laytZlT $Ifgd 00'060F0G0H0A8 $Ifgd kd.$$IfTl4    r<$`z0    h%4 laytZlT $IfgdFH0X0Y0Z0`0g0q0 $Ifgd $IfgdFq0r0u000000JAAAAAA $IfgdFkd.$$IfTl4    r<$ z0    h%4 laytZlT0000000A88 $Ifgd kd/$$IfTl4    r<$`z0    h%4 laytZlT $IfgdF0000000A88 $IfgdFkd^0$$IfTl4    r<$ z0    h%4 laytZlT $Ifgd 000 11(1)1Akd 1$$IfTl4    r<$`z0    h%4 laytZlT $IfgdF)1*1:1;1<1B1I1S1 $IfgdF $Ifgd S1T1W1e1f1g1z11JAAAAAA $IfgdFkd1$$IfTl4    r<$ z0    h%4 laytZlT11111111111111112D2u2v2y2~2222222222222222222222222 3 333303136373=3>3J3L3O3T3V3W3i3j3x3y3333333333333333h: h^hZl h*QhqS h^hqShqSh^hZlCJaJ h*QhZlhZlQ1111111A88 $Ifgd kd2$$IfTl4    r<$`z0    h%4 laytZlT $IfgdF11111u2A8 $IfgdqSkdf3$$IfTl4    r<$ z0    h%4 laytZlT $Ifgd u2v2y2222222 $IfgdFwkd(4$$IfTl    $h%  0    h%4 lap yt T22222222JAAAAAA $IfgdFkd4$$IfTl4    r<$`z0    h%4 laytFT22222222A?kd5$$IfTl4    r<$ z0    h%4 laytFT $IfgdF22 3333/303Akdi6$$IfTl4    r<$`z0    h%4 laytFT $IfgdF031373>3H3I3J3K3 $IfgdFK3L3O3U3V3W3j3y3JAAAAAA $IfgdFkd97$$IfTl4    r<$ z0    h%4 laytFTy33333333Akd 8$$IfTl4    r<$`z0    h%4 laytFT $IfgdF33333333Akd8$$IfTl4    r<$ z0    h%4 laytFT $IfgdF3333333344 4 44444!4&4(4)4;4<4J4K4Z4\4]4n4o4t4u4{4|444444444442535A5B5C5e5f5g5i5j5n5o5w5y5߾h*Qh&!5h*QhX5 h*Qh h*Qh&! h*Qh~h~ h*Qh ' h 'h 'j<hUjhU h 'hh h^hZlh^hZlCJaJ h*QhZlhZl833333344Akd9$$IfTl4    r<$`z0    h%4 laytFT $IfgdF44 4444!4'4Akdy:$$IfTl4    r<$ z0    h%4 laytFT $IfgdF'4(4)4<4K4[4\4]4AkdI;$$IfTl4    r<$`z0    h%4 laytFT $IfgdF]4m4n4o4u4|444Akd<$$IfTl4    r<$ z0    h%4 laytFT $IfgdF4f5g5h5i5yy$Ifwkd]=$$IfTl    $h%  0    h%4 lap yt(T $Ifgdi5j5k5m5{{ $IfgdNmzkd >$$IfTl    0H$0    h%4 laytKTm5n5o555{{r $Ifgd, `gd zkd>$$IfTl    0H$0    h%4 layt&!Ty5z5{5|55555555555555555556666E7F7J7K7Y7Z7[7\7`7777777777ٻٻͰ٪͆ٻ{wshyhwjAhRkUjyAhRkUh*Qh CJ hZlCJh:hy5CJ hyCJjM@hRkU h*Qh&!j?hRkUhVjhVU h*Qh h*Qh 5h5Qh*Q5 h~h*Qh9WCh*Q5+555555F7uuug  !$Ifgd, $$Ifa$gd, $Ifgd,ukd?$$IfTl    $h%   0    h%4 lap yta-TF7G7J7`777.9`WKKKW $$Ifa$gd, $Ifgd,kd@$$IfTl    \e $   q 0    h%4 laytwT77-9293949B9C9D9H9n9o9p9~9999999#:$:::::::::::::::;;;;;;;;;;;;;α󐿐 hhh0JOJPJQJ^J h*QhyhwjEhRkUjDhRkU h*Qh_ h*Qhx$h:jChRkU h*Qh&!j ChRkUjhVUhV h*Qh hyh:hy50.9/929H9o99:`WKKKB $Ifgd_ $$Ifa$gd, $Ifgd,kdeB$$IfTl    \e $q0    h%4 laytVT:::::;;^UIIIU $$Ifa$gd $IfgdkdC$$IfTl    \e $q0    h%4 laytVT;;;<<< =^YOJJ> $$Ifa$gd,gd dxgdL,gdkdE$$IfTl    \e $q0    h%4 laytVT;;;;;;;;<<%<2<t<w<<<<<<<<<<<<<<<<<<<<<== === =&=(=÷î۷å÷|w|p|i| h*QhZl h*Qh#OG h:5 h*Qh hZl5 h9a5h*Qh5h*Qh&!5h*Qh 5h9a5CJaJhZl5CJaJh2h 5CJaJh2h&!5CJaJh2h8-5CJaJh2ho5CJaJhhho5CJaJhhh 5CJaJ) = = =~ $$Ifa$gd,ukd=F$$IfTl    $h%   0    h%4 lap yta-T = = ==#gkdG$$IfTl    $h%0    h%4 layt T $$Ifa$gd,gkdF$$IfTl    $h% 0    h%4 laytwT====gkdH$$IfTl    $h%0    h%4 layt T $$Ifa$gd,====#gkdI$$IfTl    $h%0    h%4 layt T $$Ifa$gd,gkdH$$IfTl    $h%0    h%4 layt T====gkdI$$IfTl    $h%0    h%4 layt T $$Ifa$gd,====#gkdJ$$IfTl    $h%0    h%4 layt T $$Ifa$gd,gkdJ$$IfTl    $h%0    h%4 layt T====gkdK$$IfTl    $h%0    h%4 layt T $$Ifa$gd,=== =#gkdL$$IfTl    $h%0    h%4 layt T $$Ifa$gd,gkdK$$IfTl    $h%0    h%4 layt T =!="=#=gkdL$$IfTl    $h%0    h%4 layt T $$Ifa$gd,#=$=%=&=#gkdM$$IfTl    $h%0    h%4 layt T $$Ifa$gd,gkd"M$$IfTl    $h%0    h%4 layt T&='=(=)=*=Q=e=u $$Ifa$gd `gd<gdWm gkd&N$$IfTl    $h%0    h%4 layt T $$Ifa$gd,(=)=*=4=5=6=7=P=Q=d=e=f=i=====>">*>I>J>X>Y>Z>>>>>>>>>>>>>>>>>̋vhj7PhhJh<UjOhhJh<U hhJh<jhhJh<UjKOhhJhZlU hhJhZljhhJhZlUhZl h*QhZlh,h<CJaJ h*Qh<h5Qh<5 h~h<h9WCh<5 h<5h*Qh<5h*Qh5(e=f=i=>>~uu $Ifgd ` $$Ifa$gd `ukdN$$IfTl    $h%  0    h%4 lap yt<T>>>>>>cZNNN $$Ifa$gd ` $Ifgd<kdP$$IfTl    F$.t0    h%    4 lapyt<T>>>>>>G;222 $Ifgd ` $$Ifa$gd `kdnQ$$IfTl4    \ P$`.   0    h%4 lap(yt<T>>>>>>G;222 $Ifgd ` $$Ifa$gd `kdSR$$IfTl4    \ P$ .   0    h%4 lap(yt<T>>>>>???? ? ????????%?'?@@BE E)E-EE,,,,,,,,,,,,,ž~yuqumufu h*QhB>h<h(hB> hqS5UhZl h;:hqSh:hqS h*QhWm h*Qhh*QhWm 5B*phh*QhT+5h5Qh*Q5 h~h*Qh9WCh*Q5 h<5 hxPL5 hi5 hV5 h5h*Qh<5h,h<CJaJ h*Qh<(>>>>>?G;222 $Ifgd ` $$Ifa$gd `kd2S$$IfTl4    \ P$ .   0    h%4 lap(yt<T?????GB94gdWm  `gdJ~gd<kdT$$IfTl4    \ P$ .   0    h%4 lap(yt<T?&?'?f@g@BBCCDD,sssssssjs $IfgdqS $$Ifa$gdqSwkdT$$IfTl    c%%   0    %4 lap yt;T $IfgdU understand the falsification of any information on this application may result in administrative action, including a fine, suspension, or revocation of the license. Signature of Applicant, Owner or Chief Executive: Date: Print Name: Title:  Mail completed application to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399     DBPR-DDC-224 - Application for Permit as a Health Care Clinic Establishment Incorporated by rule: 61N-2.006, F.A.C. Eff. Date: April 2016 Page  PAGE 2 of  NUMPAGES 8 ,,,,,,,, $IfgdUgkdU$$IfTl    Ic%% 0    %4 layt#OGT $Ifgd#j,,,,,,,{{{{{ $IfgdUzkdGV$$IfTl    0c%x0    %4 layt(T,,,,-N-g-~-----occcaaa $H^Ha$gdB_O$H[^H`[a$gdB_Ogd$zkdV$$IfTl    0c%x0    %4 layt(T ,,,--~---------------------.....!.".(.).*.+./.0.:.;.<.=.>.úòsshCJaJmHnHujhB_OhCJUaJhB_OhCJaJhCJaJhCJaJh<CJaJhCJaJh:G^hCJhh(h%hKjhKUh"hB_OCJaJhB_OhB_OCJaJ h*Qh" h*QhB>+------------..>.?.@.A.B.C.D.gd$gdgdoW$a$gd:G^>.?.@.A.B.C.D.h"hKh(h%h hK5h61h/R :pJYV/ =!"#$% $$If!vh#v#v:V l. 0    h%6,55/  / 4pyt TvDeCheck54vDeCheck56vDeCheck57$$If!vh#v#v:V l 0    h%6,55/ 4ytKT$$If!vh#v#v:V l 0    h%6,554yte=T$$If!vh#vh%:V l  0    ,5h%/  /  4p yt(TtDeCheck1tDeCheck2$$If!vh#vh%:V l4  0    ,5h%/  4f4p ytCT$$If!vh#vh%:V l  h%5h%/  /   4p yt(T$$If!vh#vh%:V l  h%5h%/ /  /  4p yt(Tw$$If!vh#vh%:V lh%5h%/ /  /  4yta-T$$If!vh#vh%:V l  h%5h%/ /  /  4p yt Tw$$If!vh#vh%:V lh%5h%/ /  /  4yta-T$$If!vh#vh%:V l  h%5h%/ /  /  4p yt(TtDeCheck5tDeCheck5w$$If!vh#vh%:V lh%5h%/ /  /  4yta-T$$If!vh#vh%:V l  h%5h%/ /  /  4p yt(Tw$$If!vh#vh%:V lh%5h%/ /  /  4ytx$Tw$$If!vh#vh%:V lh%5h%/ /  /  4ytx$T$$If!vh#v#vT#v :V lh%55T5 /  / / / / / /  4yta-TtDeCheck5$$If!vh#vh%:V l  h%5h%/ /  /  4p yt(Tw$$If!vh#vh%:V lh%5h%/ /  /  4ytT$$If!vh#v#vT#v :V lh%55T5 /  / / / / / /  4ytVT$$If!vh#v#v:V lh%55/  /  / /  4ytI;T$$If!vh#v#v* #vZ :V lh%55* 5Z /  / / / / / /  4yta-T$$If!vh#vh%:V l1  h%5h%/ /  /  4p yt(T$$If!vh#vh%:V lL  h%5h%/ /  /  4p yta-T$$If!vh#vh%:V l0    h%5h%4ytTw$$If!vh#vh%:V lh%5h%/ /  /  4ytT$$If!vh#v#v#v6 :V lh%5556 /  / / / / / /  4ytT$$If!vh#v#v:V lh%55/  /  / /  4yt#jT}$$If!vh#vh%:V l4h%5h%/ /  /  4f4yt `T$$If!vh#vh%:V lC  h%5h%/ /  /  4p yt(T$$If!vh#vh%:V lC  h%5h%/ /  /  4p yta-T$$If!vh#vh%:V l0    h%5h%4ytTw$$If!vh#vh%:V lh%5h%/ /  /  4yt<T$$If!vh#v#v#v6 :V lh%5556 /  / / / / / /  4ytx$T$$If!vh#v#vh:V l"h%55h/  /  / /  4ytLiT$$If!vh#v6 #v#vh:V l8h%56 55h/  / / / / / /  4ytLiTvDeCheck14vDeCheck14vDeCheck14vDeCheck14vDeCheck14$$If!vh#v#v:V l* h%55/  /  / /  4pyt<Tw$$If!vh#vh%:V lh%5h%/ /  /  4yt<T$$If!vh#v#v:V lh%55/  /  / /  4yt<T$$If!vh#vh%:V l^  0    h%5h%/ 4p yt(T$$If!vh#vh%:V l-0    h%5h%/ 4yt#OGT$$If!vh#v:V l0    h%5/  4ytI;T$$If!vh#vh%:V l  0    h%5h%/  /  4p yt(TtDeCheck3tDeCheck4tDeCheck5$$If!vh#v|#v@ #v :V lh%5|5@ 5 /  /  /  /   / 4ytL`TvDeCheck10tDeCheck9tDeCheck6$$If!vh#v|#v@ #v :V lh%5|5@ 5 /  / /  4ytL`TvDeCheck11tDeCheck8tDeCheck7$$If!vh#v|#v@ #v :V lh%5|5@ 5 /  / /  4ytL`TvDeCheck11vDeCheck12$$If!vh#v|#v@ #v :V lh%5|5@ 5 /  / / /  4yta-TvDeCheck12$$If!vh#vh%:V l  0    h%5h%/ 4p yt(T$$If!vh#vh%:V l0    h%5h%/ 4p yta-TvDeCheck12$$If!vh#vh%:V l  0    h%5h%/ 4p yt(T$$If!vh#vh%:V l0    h%5h%/ 4yt)T$$If!vh#vh%:V l0    h%5h%/ 4yt)T$$If!vh#v#v#v:V l0    h%555/ 4yta-T$$If!vh#vh%:V l  0    h%5h%/ 4p yt(T$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vz#v#v#v#v:V l40    h%+5z55554ytZlT$$If!vh#vh%:V l  0    h%5h%4p yt T$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFT$$If!vh#vz#v#v#v#v:V l40    h%+5z5555/ 4ytFTtDeCheck5$$If!vh#vh%:V l  0    h%5h%/ 4p yt(T$$If!vh#v:V l0    h%5/ 4ytKT$$If!vh#v:V l0    h%54yt&!T$$If!vh#vh%:V l  0    h%5h%/  /  4p yta-TvDeCheck13vDeCheck14$$If!vh#v#v#v#vq:V l0    h%5555q/  4ytwTvDeCheck24vDeCheck15$$If!vh#v#v#v#vq:V l0    h%5555q4ytVTvDeCheck23vDeCheck16$$If!vh#v#v#v#vq:V l0    h%5555q4ytVTvDeCheck20vDeCheck19$$If!vh#v#v#v#vq:V l0    h%5555q4ytVT$$If!vh#vh%:V l  0    h%,5h%/  /  4p yta-T$$If!vh#vh%:V l0    h%5h%/  4ytwT$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l0    h%5h%4yt T$$If!vh#vh%:V l  0    h%,5h%4p yt<TvDeCheck26vDeCheck25vDeCheck26$$If!vh#v.#v#vt:V l0    h%,5.55t4pyt<T$$If!vh#v.#v #v #v :V l40    h%+,5.5 5 5 4p(yt<T$$If!vh#v.#v #v #v :V l40    h%+5.5 5 5 4p(yt<T$$If!vh#v.#v #v #v :V l40    h%+5.5 5 5 4p(yt<T$$If!vh#v.#v #v #v :V l40    h%+5.5 5 5 4p(yt<T$$If!vh#v%:V l  0    %5%/  /  4ap yt;T$$If!vh#v%:V lI0    %5%/  4ayt#OGT$$If!vh#vx#v:V l0    %5x54ayt(T$$If!vh#vx#v:V l0    %5x54ayt(T^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH N`N XNormal%B*OJQJ^J_HmH phsH tH >@>  Heading 8$$@&a$5DA`D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List 8@8 Header  !CJ<P@< Body Text 2dCJ>B@> Body Text$da$CJbo"b m=Default 7$8$H$-B*CJOJQJ^J_HaJmH phsH tH 4 @24 j*Footer  !.)A. j* Page Number6U`Q6 !8 Hyperlink >*B*phFV`aF ,FollowedHyperlink >*B* phH@rH  Balloon TextCJOJQJ^JaJ*/*2Style3 F $O$ number<< text intro justify o #jtextjj < Table Grid7:V0PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] = <  D  :"&'()*/13y57;(=>,>.D.#&(+-/37?DIJLOSZfqy|l H Rz2^o !Q!!"%%&x((:))T**+,---.///0H0q0000)1S111u222203K3y3334'4]44i5m55F7.9:; = ======= =#=&=e=>>>>??,,,-D.$%')*,.01245689:;<=>@ABCEFGHKMNPQRTUVWXY[\]^_`abcdeghijklmnoprstuvwxz{}~}$Zjw4DK[`pvp+;Qao ! z k!{!E#U#**f+v+++--C-S-..+/;/p000044<4L4U4e4=G,G,G,G,G,G$G$G$G,G,G,G,G,G,G,G,G,G,G,G,G,G,G,G,G$G$G$G,G,G,G,G,G,G,G,G$G$G$!@ @H 0(  0(  B S  ? _Toc519479633Check54Check56Check57Check1Check2 _Toc528030815Check3Check4Check5Check10Check9Check6Check11Check8Check7Check13Check14Check24Check15Check23Check16Check20Check19~[q,Rpg++-D-.,/q00= %,k<bw++-T-/?@ABCDEFG 55__===='=+==       <<ff==%=)=0=0== > *urn:schemas-microsoft-com:office:smarttags PostalCode8*urn:schemas-microsoft-com:office:smarttagsCity:*urn:schemas-microsoft-com:office:smarttagsStreet;*urn:schemas-microsoft-com:office:smarttagsaddress9*urn:schemas-microsoft-com:office:smarttagsplace9*urn:schemas-microsoft-com:office:smarttagsState 8OM  2=4=5=7=8=:=;===>===17jlrt;=2=4=5=7=8=:=;===>===33333333333$$"$01bc 1=>bcjmuo$HllmnMO45566 !!!!##J%L%!+*+*+,,,,//u1x111\2\22222222222%3;4l4l4444X<g<<<<<<1=2=2=5=5=>=B=D=======$$"$01bc i j 1=>bcjmuo$HllmnMO45566 !!!!##J%L%%%%%%%%%%%&&&&&&"&#&,&.&s&u&&&&&&&&&&&&&&&''''U'W'h'i'n'o'u'v'''!+*+*+,,,,//u1x111\2\22222222222%3;4l4l4444X<g<<<<<<1=2=2=4=5=5=7=8=:=;===>=@=d=j========1 D1B@7 Ǹ1,hX,# do.!j?QL|6 4U!l2!~ #6V_$ut ,~ 3*] {4Xd6g+CH$N0L~ R-N&TsP!xtY E0dz2nEdP$snJ7s*WOz ~6fw^`o(. ^`hH. pLp^p`L5hH. @ @ ^@ `5hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.  ^ `OJPJQJ^Jo(q88^8`OJQJ^Jo(hHo^`OJQJo(hH  ^ `OJQJo(hH  ^ `OJQJ^Jo(hHoxx^x`OJQJo(hHHH^H`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH88^8`o() ^`hH.  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.h^`CJo(.h TT^T`hH.h $ L$ ^$ `LhH.h   ^ `hH.h ^`hH.h L^`LhH.h dd^d`hH.h 44^4`hH.h L^`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h^`CJo(.h^`CJaJo(hH) $ $ ^$ `CJaJo() @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.^`o(. ^`o(hH. pLp^p`L5hH. @ @ ^@ `5hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h^`CJo(.h^`CJaJo(hH)$ $ ^$ `CJo() @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h"^`B*CJOJQJo(phhHqh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH hh^h`o(hH. 88^8`o(hH. ^`o(hH. ^`o(hH. pp^p`o(hH.   ^ `o(hH. @ @ ^@ `o(hH. ^`o(hH. L^`Lo(hH.h hh^h`o(hH.h 88^8`o(hH.h^`5o(hH.h^`B*o(phhH()h pp^p`o(hH()h   ^ `o(hH()h @ @ ^@ `o(hH.h ^`o(hH.h L^`Lo(hH.h"^`B*CJOJQJo(phhHqh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH^`o(.8 ^`o(hH. pLp^p`L5hH. @ @ ^@ `5hH.^`56hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`56o(hH.8 ^`o(hH.pLp^p`L5o(hH.@ @ ^@ `5o(hH.^`56o(hH. L^`Lo(hH. ^`o(hH. ^`o(hH. PLP^P`Lo(hH. ^`CJaJo(.8^`CJaJo(hH) pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h^`CJo(.h^`CJo(hH.$ $ ^$ `CJo() @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h"^`B*CJOJQJo(phhHqh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH^`CJOJQJo(q8^`QJo(- PP^P`OJQJo(   ^ `OJQJo(   ^ `OJQJo(o ^`OJQJo( ^`OJQJo( ``^``OJQJo(o 00^0`OJQJo(hh^h`OJPJQJ^Jo(q88^8`OJQJ^Jo(hHo^`OJQJo(hH  ^ `OJQJo(hH  ^ `OJQJ^Jo(hHoxx^x`OJQJo(hHHH^H`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`o(. ^`hH. pLp^p`L5hH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o(. ^`o(hH. pLp^p`L5hH. @ @ ^@ `5hH.^`56hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h hh^h`hH.h 88^8`5hH.hL^`L56hH.h   ^ `hH.h   ^ `hH.h xLx^x`LhH.h HH^H`hH.h ^`hH.h L^`LhH.h ^`hH.h pp^p`hH.h @ L@ ^@ `LhH.h ^`hH.h ^`hH.h L^`LhH.h ^`hH.h PP^P`hH.h  L ^ `LhH.h hh^h`hH.h88^8`56o(hH.hL^`L56hH.h   ^ `hH.h   ^ `hH.h xLx^x`LhH.h HH^H`hH.h ^`hH.h L^`LhH.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHz ~0d#g+CxtY1 |6J7snEd3 {4 B@7 T_$R-NLj? dot ,2!,,$s#d6H4U!@  hh^h`o(hH.p! 88^8`o(hH." ^`o(hH.# ^`o(hH()0$ pp^p`o(hH()`%   ^ `o(hH()& @ @ ^@ `o(hH.' ^`o(hH. ( L^`Lo(hH.uz]        fv         .                 .6*,D\               %d6*       $q              F,wi~               4Xws&l d CN/S62VN/M"s&N/tn"cjH1S6OvKN/tn"cCzMDe+BYiN/bsXwM"CzbsysUEW[\Rko -9XP}A%)e12W6\(,o=e@%DJn D  */ G )I Wm " h   y$ H Z j n % ( TbsO-hn z,W$O')wNTgr$u$ YhAz%%'U(E.:<H5>*tRa 5bfRg~0jlOQ.G#K~I&]n >7VZ} " ;!B!&!"=" #J\#o#B%I%ho%&B& '(+(64(#P(|V()[)U)g)?-*0*j*1q*+-+oo+*,A,C,J,L,|,.-a-R}-6. e./9/"a0f01%f1o12,2RW2d2dp2C 3,3_[3 s3Op4 555K5u57a.7Q7hj7 9C9l9:R:l:];;I;r;m=Ti=c>B>9>G>k>9?@?2AVDqEG'Ff)FX1F*SF GG#OGBOGq Hq_HVIrJhJ@ALxPLDHMjMi[N5OROB_O P!/PVP*Q1dQ,NR~WRffRM-SGSqSDuSBT`TU`UvUJYV7WOWoWX"X_3X?X0GYGYPYpZ%Z3lZw[)[\ \a\|\]]I]#]*4]8 ^:G^g^ `?'`L`0a9ab,bHbHc[ cecHcwc'dEEdeeZf1*gE=gPg'hS.h2^hihLiLi#j0jXjljyj`klTlZl`lhl)m*GmHmNm`]masmymnqqnoo!o p,pgpu*q.q6r"sL&s33s6sas\bslsusp t%t1t$u ^uqv/x\x:sx yayXzz,zK4zz{ES{Z{!t{1%|-|l@|}H}Pb}~xiwb-FqE:EPO0VYj 9 j%H5r1Ee+^cI"o7 x @^oPy RYMmP%n'1bt7%0#%%im!P1iz2S29}ZGdtty!4kkO:C]x$~d9[ ,,>D- =CKLU&wJ~9 h;\w&'8&^z[#Wcr 3B)7`vxNU4YoG!nX~v#dB 4` Mmyr2xAPkB@k,8.?@[cj.;X OV[ ~4 '`E,xD 2,acu7o_M\h ()4 lp' `F&s? :)F$,tFKmb!<R| e=\a1">UfT+kLj ?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !&'*Root Entry FUMĦ)Data qW1TableWordDocument 8<SummaryInformation(DocumentSummaryInformation8MsoDataStoreUMĦUMĦYIGPBO4ZIA==2UMĦUMĦItem  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q