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Clear Form MV3644 1/2013 Ch. 343 Wis. Stats. & Trans. 112 Admin. Code APPLICANT: After this medical report has been reviewed, you may be required to file medical reports on a regular basis. We will send you the forms at the time they are required. Applicant Name Operator License Number Street Address Birth Date (m/d/yy) City, State ZIP Code (Area Code) Telephone Number Date Report Issued (m/d/yy) WisDOT Examiner Badge Number License Type Instruction Perm.

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