INITIAL APPLICATION FOR LICENSURE
Form ILA 3 Rev 7/2016 Section VI: Disciplinary Actions and Criminal History Data A. Has any health related professional licensing or disciplinary body in any state, territory or foreign jurisdiction denied, limited, placed on probation, restricted, suspended, cancelled or revoked any professional license,
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www.bot.ca.govRevised 7/2017 BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR. T REQUEST FOR DUPLICATE LICENSE / PERMIT Type of license being requested:
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