CSR Application Form 01 27 2011 - Department of Public Health ... - dphss guam-2025

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The document is an application form from the Department of Public Health and Social Services in Guam for individuals seeking to prescribe, administer, or dispense controlled substances. It includes sections for personal information, professional credentials, and legal compliance regarding controlled substances. The form requires verification of current authorization and registration with relevant authorities, along with a declaration of any felony convictions related to controlled substances.

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