Form Dwc-97 - Health Care Provider Application For Certification 1994 Page 2

The following photocopy attachments are required with this application if you are NOT LICENSED by the Agency for

Health Care Administration, either:

- CURRENT FLORIDA MEDICAL SCHOOL TEACHING CERTIFICATE;

- CURRENT TEMPORARY CERTIFICATE IN AN AREA OF CRITICAL NEED PURSUANT TO S. 458.315, FLORIDA

STATUTES, FOR MEDICALLY CRITICAL AREAS.

Signature

Date

IMPORTANT! The Division will return a copy of this page within 90 days of receipt as proof of your certification. In

order to insure and expedite this process, please print or type your mailing address in the box below.

MAILING ADDRESS:

DIVISION CERTIFICATION STAMP

For office use only:

CERTIFICATION:

CONFERRED

DENIED

REASON FOR DENIAL: ___________________________________________

________________________________________________________________

Additional requirements needed:

Yes

LES Form DWC-97 (10/15/94)

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