ࡱ> #` $Sbjbj S :  `$`$`$8$4% eD&"&)&)&)&)012|CCCCCCC$cFhHC] 5.l055C&)&)D8989895X&) &)C895C8989:L>D @ d?&)% ac`$5X? p@,5D0eD?RYIH6YId?YI d? 93h3J893<'4q939393CC8X939393eD5555 \ \  OREGON HEALTH LICENSING AGENCY Susan K. Wilson, Director 700 Summer St NE ( Suite 320 Salem, Oregon 97301-1287 Phone (503) 378-8667 TTY (503) 373-2114 Fax (503) 370-9004 Web site  HYPERLINK "http://www.oregon.gov/OHLA" www.oregon.gov/OHLA E-mail  HYPERLINK "mailto:ohla.info@state.or.us" ohla.info@state.or.us  FORMTEXT        FORMTEXT        FORMTEXT       Student Name Social Security Number Date Of Birth  FORMTEXT        FORMTEXT       Name of School School License Number  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Address City State Zip Code Check left-hand column to specify categories of additional training student received and indicate number of hours for each. 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