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KG (Lead placement must be verified by physician) Hearing test - pure tone air conduction audiogram results (Attach printout or record results on page 10.) CSO must be positioned in such a way that he is unable t o visually detect the administration of tones during testing. -Vision test results NAME (Last, First, Midde-Type or print): Soc. Sec. No.: Circuit: District: Applicant Incumbent 0 Sex: Date of Birth: Years in Position: Date of Exam: CI , authorize my employer and an examini.

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