Reciprocity Verification Form A - Texas Department of State Health Services
Austin, Texas 78714-9347 PHONE (512) 834-6734 FAX (512) 206-3779 emscert@dshs.texas.gov Please return to TX by e-mail. Reciprocity Verification Form A. State Seal. #OF PAGES NAME OF STATE AND AGENCY COMPLETING FORM EMS OFFICE FAX NUMBER. Date. Applicant’ Last Name First Name. Middle Name Social Security Number. Certificate/License number ................
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