Get Form Approved Budget Bureau No 50 R0073
Rt A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE (typewrite or print in ink) 1. NAME (last, first, middle) 2. SOCIAL SECURITY ACCOUNT NO. 3. 4. SEX DATE OF BIRTH MALE FEMALE 5. DO YOU HAVE ANY MEDICAL DISCORDER OR PHYSICAL 6. IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH THE FULL PERFORMANCE OF THE DUTIES SHOWN BELOW? YES I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION WITH THIS EXAMINATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. NO (If your answer is YES, exp.
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