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Get Lic 603

Es NOTE: This information may be obtained from the applicant, or his/her authorized representative. (Relatives, social agency, hospital or physician may assist the applicant in completing this form.) This form is not a substitute for the Physician s Report (LIC 602). APPLICANT S NAME AGE HEALTH (Describe overall health condition including any dietary limitations) PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech) MENTAL CONDITION (Specify extent.

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