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Application for Appointment

  1. Application for Appointment Itasca County Health and Human Services Advisory Committee
  2. Are you a Service Consumer?
  3. Are you a Service Provider?
  4. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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  6. This field is not part of the form submission.