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IMPORTANT: Please have available the following documents:

  • PDF/JPG copy of a clinic utility bill (water, waste, electric, cable, landline)
  • PDF/JPG copy of your clinic's  voided check
  • Color copy front and back of the Owner's drivers license

Save for later: If you need to save this application for later, their is a link at the bottom that will allow you to do this.  Be sure to keep the link safe as this is how you will access the form at a later time.

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