State of Ohio EMS
STATE. COUNTY. ZIP CODE. SERVICE REPRESENTATIVE. REPRESENTATIVE SIGNATURE. X EMS INSPECTOR. COMPLIANCE VERIFICATION Ohio State Board Pharmacy License displayed [O.A.C. 4766-5-06(A)(6)] YES NO N/A EMS License displayed [O.A.C.4766-5-04(A)(2)] YES NO N/A Drug Enforcement Agency Registration Displayed (as applicable) [O.A.C. 4766-5-09(B)(2)] YES ... ................
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