cdph 279

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Failure to supply adequate information to meet state and federal instructor requirements will result in non-approval of application. Proof of 24-hour BRN approved DSD class or transcript of college courses related to education programs in nursing. Copy of active nursing license. Name Telephone Number Mailing Address Number and Street or P. O. Box Number City Zip Code Administrator / Program Director Signature and Title Printed Name Date Director of Nursing Signature FOR OFFICE USE ONLY...
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