New York State Medicaid. Enrollment Form. Thank you for your interest in enrolling with the New York State Medicaid Program. DISCLOSURE OF OWNERSHIP AND. NOTE: This financing disclosure is mandated for use by lenders originating real estate. Borrower acknowledges receipt of a copy of this disclosure statement. Date: ______, 20______. Borrower's Signature: Borrower's Signature: FORM 221.

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• • • • • • • • •, including: • Mailing addresses • Instructions for forms • FDA's receipt of the IND Forms: • ): Investigational New Drug Application (IND) •: Statement of Investigator •: Certification of Compliance •: Certification: Financial Interests and Arrangements of Clinical Investigators •: Disclosure: Financial Interest and Arrangements of Clinical Investigators •: MedWatch Medical Product Reporting Program - Voluntary •: Medwatch Medical Products Reporting Program - Mandatory •: Individual Patient Expanded Access Applications • For electronic form submissions, see.