NYS DOH Form-4453 Duplicate Card Request Submission

Name and Address
I affirm that in accordance with the requirements of 10NYCRR Part 800. (e), I have not been convicted of or am not currently charged with any misdemeanors or felonies. I understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar to certification. The Department of Health will determine if the conviction is applicable under the provisions of 10NYCRR Part 800.
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