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Agency Information
This form needs to be completed by November each year to be compiled for NYS DOH requirements. Respond NA to any question not applicable to your agency.
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Email
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Your email
Agency Name
*
Your answer
Agency #
*
Your answer
Agency Physical Address
Your answer
Agency Mailing Address Part 1
Same as Physical Address: Skip next question.
Other: Complete the next question.
Agency Mailing Address Part 2
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Agency Phone
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Agency Fax (if available)
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