State Form 46159 - Application For Permit To Administer Anesthesia And Sedation For Dentists Page 3

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DISCIPLINARY INFORMATION
(If yes, provide information below and submit a sworn statement giving full details.)
month, day, year
(except for violation of traffic laws resulting in fines.)
month, day, year
AUTHORIZATION FOR RELEASE OF INFORMATION
AUTHORIZATION FOR RELEASE OF INFORMATION
To whom it may concern:
VERIFICATION
month, day, year
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