Certificate Of Eligibility - Division Of Policy And Shortage Designation Bureau Of Health Workforce, Health Resources Services Administration Page 4

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By signing, I represent and confirm that I am fully authorized to bind the covered
entity and certify that the contents of any statement made or reflected in this
Certificate of Eligibility are truthful and accurate.
Name of RHC Authorizing Official
Title
RHC Authorizing Official E-mail
Phone Number:
Signature of RHC Authorizing Official
Name of RHC Alternate Contact
Title
Alternate Contact E-mail
Phone Number
Date Submitted
SUBMIT Certificate of Eligibility TO ---------------> SDB@hrsa.gov (Attention: Tracey Martin and
Kristen Jackson). Processing of this information is subject to approval and verification by the
Division of Policy and Shortage Designation.
Shortage Designation Internal Review
Date Received
Approve
Disapprove
Other
Approving DPSD Official Signature
Adjudication Date

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