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DOH-2973(f) - Wadsworth Center - wadsworth-2026
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- Click ‘Get Form’ to open the DOH-2973(f) in the editor.
- Begin with Part I, entering the name of the bank, address, city, state, zip code, and telephone number. Ensure all information is accurate as it is crucial for your application.
- Move to Part II – Ownership Information. If the owner’s name differs from the tissue bank name, provide the owner's name and address. Define direct and indirect ownership interests as outlined in the form.
- Answer whether any owners or board members have ownership interests in other licensed facilities. If yes, list their names and addresses.
- In Part III – Declaration, indicate if any individuals have been convicted of healthcare fraud or related charges. Provide details if applicable.
- Complete Part IV by signing and dating the form. Include your title and contact information before submission.
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| 2013 | 4.8 Satisfied (165 Votes) |
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