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1600 Veterans DrivePO Box 673 Lisbon, ND, 58054-0673 Admissions (701) 683-6540 Fax (701) 683-6550 -

1600 Veterans DrivePO Box 673 Lisbon, ND, 58054-0673 Admissions (701) 683-6540 Fax (701) 683-6550 - -2025

1600 Veterans DrivePO Box 673 Lisbon, ND, 58054-0673 Admissions (701) 683-6540 Fax (701) 683-6550 - Preview on Page 1

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The document is an application form for admission to the North Dakota Veterans Home, requiring personal, medical, and military information from applicants. It includes sections for demographic details, type of care needed, insurance information, legal documentation, family contacts, financial responsibilities, hospitalization history, current health problems, and a certification of residency. The form emphasizes compliance with privacy regulations and non-discriminatory practices.

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