Form Sf 43813 - Application For License Approval To Operate A Hospice Program - Indiana Department Of Health Page 5

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If signed by any individual other than the Chairman or President of the
organization, an affidavit must be submitted with the application, affirming that
said person has been given the power to bind the applicant.
____________________________________
______________________________
Name of Authorized Representative (Typed)
Title
____________________________________
______________________________
Signature of Authorized Representative
Date
5

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