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Get Printable Form 649 F

Security No. Address City, State, Zip Code Birthdate Work Tel: ( Home Tel: ( Age Sex New Certification Date of Exam M Recertification F Follow-up ) Driver License No. License Class State of A C Issue ) B D Other E L 2. HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver. Yes No Yes No Yes No Any illness or injury in the last 5 years? Lung disease.

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